Orthopedic Teleradiology

Patient consent(Required)

Patient gave consent for consultative services

Type of Request(Required)

If emergency transport is required do not use this form call 907-729-2337

A phone call to Ortho Field Support surgeon is required for all medically urgent telerads.
M-F from 8am-5pm: Call the ANMC Ortho Field Support office at 907-729-1791.
After 5pm and on weekends: Call the ANMC operator at 907-563-2662 to contact the on-call surgeon.

Click here if this case needs to be priorized for travel.

Routine:
Non-urgent telerads received outside of M-F, 8am-5pm will be reviewed the next business day.

Supplemental Information:
For supplemental information only (demographics, insurance info, clarifying documentation). Not intended for new radiographic images.

Requesting Organization(Required)

Other Requesting Organization

History(Required)

Patient Information

Patient First Name(Required)

Patient Last Name(Required)

Patient Date of Birth(Required)

Patient Phone Number

This field is hidden when viewing the form

Patient First Name

This field is hidden when viewing the form

Patient Last Name

This field is hidden when viewing the form

ANMC Chart Number

This field is hidden when viewing the form

Patient DOB

Clinical History

Include specific question for consulting orthopedic surgeon and adequate detail to assist in making medical decisions.

Date of Injury(Required)

Date of Exam/X-ray(Required)

Mechanism of injury and/or pertinent history(Required)

This field is hidden when viewing the form

Patient First Name

This field is hidden when viewing the form

Patient Last Name

This field is hidden when viewing the form

ANMC Chart Number

This field is hidden when viewing the form

Patient DOB

Clinical Exam

All exam fields below are required or enter N/A.

Specific Body Part(s) Involved(Required)

Laterality(Required)

Neuro Status/Exam(Required)

Neuro Status/Exam Details(Required)

Vascular/Perfusion(Required)

Vascular/Perfusion Details(Required)

ROM(Required)

ROM Details(Required)

Wound/Incision Status(Required)

Wound/Incision Status Details(Required)

Point of Tenderness (Specify Location)(Required)

Point Tenderness Details(Required)

Patient has an ANMC chart

If patient does not have an ANMC chart, please upload the demographic form using the file upload field below

Optional Document Upload (JPG, PNG, PDF)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 10.

This field is hidden when viewing the form

Patient First Name

This field is hidden when viewing the form

Patient Last Name

This field is hidden when viewing the form

ANMC Chart Number

This field is hidden when viewing the form

Patient DOB

Provider Information

Complete information is required for ALL submissions

Provider First Name(Required)

Provider Last Name(Required)

Provider NPI Number (DO NOT SKIP)(Required)

Please enter 10 digit Provider NPI

Direct Phone Number (Preferred)(Required)

Hospital/Department Phone Number(Required)

Additional Provider Name

Additional Provider Phone

This field is hidden when viewing the form

Patient First Name

This field is hidden when viewing the form

Patient Last Name

This field is hidden when viewing the form

ANMC Chart Number

This field is hidden when viewing the form

Patient DOB

To save a copy of form, before clicking submit:

right click on the screen
select print
choose “Save as PDF”
upload to your EHR