Orthopedic Teleradiology

Patient consent(Required)

Patient gave consent for consultative services

Type of Request(Required)

Emergent Cases:
A phone call to Ortho Field Support surgeon is required. 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.

Non-urgent Cases:
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)

ANMC Chart Number

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

Referring Provider Name(Required)

Credentials(Required)

Provider NPI Number (DO NOT SKIP)(Required)

Please enter 10 digit Provider NPI

Provider's Organizational Email(Required)

This email will be used to confirm the receipt of submission.

This field is hidden when viewing the form

Provider's Organizational Email

This email address will be used to confirm the receipt of submission.

Direct Phone Number (Preferred)(Required)

Hospital/Department Phone Number(Required)

Additional Contact Information (check all that apply)

Do you want results sent to an additional provider?

Are you completing this form on behalf of the provider?

Additional Provider Name

Additional Provider Phone

Submitter Name

Submitter Phone

Submitter information will be used only if needed by Ortho rep for clarification purposes.

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