CT Myelogram Request

Ordering Clinician

Is the ordering clinician at BMC?

YesNo

Patient Name

Medical Record Number or Date of Birth

Patient Contact Number

Myelogram Indication

MRI Contraindication

CT imaging ordered?

YesNo

INR(PT) <1.4, CBC (platelets >100) within three months?

YesNo

On an antiplatelet or anticoagulation agent besides aspirin 81mg?

YesNo

Which myelogram are you requesting? Check all that apply.

Cervical myelogramThoracic myelogramLumbar myelogramWhole-spine myelogram

Is your patient on any of the medications on this list?

YesNo

Are they able to hold this medication for 48 hours prior to and 24 hours after the myelogram?

YesNo

Time Frame for Request

ICD-10 Code

Request Details