The forms listed to the right are in PDF format, and require Adobe Reader, which you can download easily to your computer by clicking the button above.
A. PIC Order Form B. (blank)
This is our current requisition form last revised 10/12, the familiar two pager with the Providence Imaging Center "people" in the upper left hand corner. It lists studies available at all three of our locations in Anchorage, Eagle River and Soldotna.
C. PET-CT Order Form
D. PET-CT Bone Order Form
A PET-CT requires that we get some special information in order to get the most accurate results possible. Patients also follow a special diet.
Use this form to order an 18F-Fluoride PET-CT bone imaging scan, much more sensitive than traditional nuclear medicine bone scans (99mTc).
M. PET-CT Prep Sheet for Brain Imaging
N. PET-CT Bone Instructions
This prep ensures that we obtain the best pictures possible for patients who have a PET-CT of the brain. Instructions are applicable twelve (12) hours before your appointment.
This instructions sheet explains what is needed before you get a PET-CT bone scan; no special diet is required, however.
Q. MRI-Guided Breast Biopsy Instructions
R. Stereo-Guided Breast Biopsy Instructions
S. Ultrasound-Guided Breast Biopsy Instructions
T. Ductogram Instructions
This two page PDF that you can download and print includes helpful information on what to expect during the MRI guided procedure.
This two page PDF that you can download and print includes helpful information on what to expect during the stereo guided procedure.
This two page PDF that you can download and print includes helpful information on what to expect during the ultrasound guided procedure.
This PDF file that you can download and print includes helpful information on what to expect during a ductogram procedure.
Directions with appointment card/map
General information/reference cards
Clinic Information Card for Providers
This reference provides clinicians and staff with general information about Providence Imaging Center in Anchorage, Eagle River and Soldotna, including our services, scheduling, hours of operation, and contact information.
Order Tip Sheet for Providers
PIC Release to Medical Facility
Use this form to have PIC release films/images/report(s) to patients. Use this form to have PIC release films/images/report(s) to another medical facility or clinician.
Charity Care Financial Assistance FormProvidence Imaging Center does participate in the Charity Care program at Providence Alaska Medical Center. A form is available for patients who would like to see if they qualify for this financial assistance. After completing the form, please fax it to (907) 212-5827 or drop it off at our front desk at 3340 Providence Drive, Anchorage, AK 99508.
Registration FormTo download and print a registration form that you can fill out, click here.
© 2013 Providence Imaging Center