{"id":12500,"date":"2025-05-05T12:55:16","date_gmt":"2025-05-05T18:55:16","guid":{"rendered":"https:\/\/radiologyassist.com\/StagingAvada\/?page_id=12500"},"modified":"2025-05-26T16:38:22","modified_gmt":"2025-05-26T22:38:22","slug":"virtual-consultation-form","status":"publish","type":"page","link":"https:\/\/radiologyassist.com\/StagingAvada\/virtual-consultations\/virtual-consultation-form\/","title":{"rendered":"Virtual Consultation Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-small-visibility fusion-no-medium-visibility\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-min-height:70px;--awb-background-color:#6d0d26;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1331.2px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_4 1_4 fusion-flex-column fusion-flex-align-self-center\" style=\"--awb-padding-top:10px;--awb-bg-size:cover;--awb-width-large:25%;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:7.68%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-center fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\" style=\"--awb-font-size:18px;--awb-text-color:#ffffff;--awb-text-font-family:-apple-system, BlinkMacSystemFont, &#039;Segoe UI&#039;, Roboto, Oxygen-Sans, Ubuntu, Cantarell, &#039;Helvetica Neue&#039; ,sans-serif;--awb-text-font-style:normal;--awb-text-font-weight:400;\"><p>Appointments : 855-346-5152<\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_4 3_4 fusion-flex-column fusion-flex-align-self-center\" style=\"--awb-padding-top:10px;--awb-bg-size:cover;--awb-width-large:75%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.56%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.56%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><nav class=\"awb-menu awb-menu_row awb-menu_em-click mobile-mode-collapse-to-button awb-menu_icons-left awb-menu_dc-yes mobile-trigger-fullwidth-off awb-menu_mobile-toggle mobile-size-full-absolute loading mega-menu-loading awb-menu_desktop awb-menu_flyout awb-menu_flyout__fade\" style=\"--awb-margin-top:-16px;--awb-gap:50px;--awb-align-items:center;--awb-justify-content:flex-end;--awb-color:#ffffff;--awb-active-color:#ffffff;--awb-main-justify-content:flex-start;--awb-mobile-justify:flex-start;--awb-mobile-caret-left:auto;--awb-mobile-caret-right:0;--awb-fusion-font-family-typography:&quot;Open Sans&quot;;--awb-fusion-font-style-typography:normal;--awb-fusion-font-weight-typography:400;--awb-fusion-font-family-submenu-typography:inherit;--awb-fusion-font-style-submenu-typography:normal;--awb-fusion-font-weight-submenu-typography:400;--awb-fusion-font-family-mobile-typography:inherit;--awb-fusion-font-style-mobile-typography:normal;--awb-fusion-font-weight-mobile-typography:400;\" aria-label=\"patient-menu DSKP\" data-breakpoint=\"1024\" data-count=\"0\" data-transition-type=\"fade\" data-transition-time=\"300\"><button type=\"button\" class=\"awb-menu__m-toggle awb-menu__m-toggle_no-text\" aria-expanded=\"false\" aria-controls=\"menu-patient-menu-dskp\"><span class=\"awb-menu__m-toggle-inner\"><span class=\"collapsed-nav-text\"><span class=\"screen-reader-text\">Toggle Navigation<\/span><\/span><span class=\"awb-menu__m-collapse-icon awb-menu__m-collapse-icon_no-text\"><span class=\"awb-menu__m-collapse-icon-open awb-menu__m-collapse-icon-open_no-text fa-bars fas\"><\/span><span class=\"awb-menu__m-collapse-icon-close awb-menu__m-collapse-icon-close_no-text fa-times fas\"><\/span><\/span><\/span><\/button><button type=\"button\" class=\"awb-menu__flyout-close\" onClick=\"fusionNavCloseFlyoutSub(this);\"><\/button><ul id=\"menu-patient-menu-dskp\" class=\"fusion-menu awb-menu__main-ul awb-menu__main-ul_row\"><li  id=\"menu-item-11995\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-11995 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"11995\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/patients\/how-it-works\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">How It Works<\/span><\/a><\/li><li  id=\"menu-item-11997\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-11997 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"11997\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/imaging-center-locator\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">Imaging Center Locator<\/span><\/a><\/li><li  id=\"menu-item-11998\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-11998 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"11998\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/virtual-consultations\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">Virtual Consultations<\/span><\/a><\/li><li  id=\"menu-item-12511\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-12511 awb-menu__li awb-menu__main-li awb-menu__main-li_regular\"  data-item-id=\"12511\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/resources\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">Resources<\/span><\/a><\/li><li  id=\"menu-item-11999\"  class=\"menu-item menu-item-type-post_type menu-item-object-page menu-item-11999 awb-menu__li awb-menu__main-li awb-menu__main-li_regular fusion-flyout-menu-item-last\"  data-item-id=\"11999\"><span class=\"awb-menu__main-background-default awb-menu__main-background-default_fade\"><\/span><span class=\"awb-menu__main-background-active awb-menu__main-background-active_fade\"><\/span><a  href=\"https:\/\/radiologyassist.com\/StagingAvada\/patients\/faq\/\" class=\"awb-menu__main-a awb-menu__main-a_regular\"><span class=\"menu-text\">FAQ<\/span><\/a><\/li><\/ul><\/nav><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:30px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1331.2px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_2_3 2_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:66.666666666667%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.88%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.88%;--awb-width-medium:60%;--awb-order-medium:0;--awb-spacing-right-medium:3.2%;--awb-spacing-left-medium:3.2%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2 gravity-contact-form\" style=\"--awb-content-alignment:left;--awb-font-size:18px;--awb-line-height:24px;--awb-text-color:#520a1c;--awb-text-font-family:&quot;Open Sans&quot;;--awb-text-font-style:normal;--awb-text-font-weight:400;\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_60' style='display:none'><div id='gf_60' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_60' id='gform_60'  action='\/StagingAvada\/wp-json\/wp\/v2\/pages\/12500#gf_60'>\n                        <div class='gform_body'><div id='gform_page_60_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_60' class='gform_fields top_label form_sublabel_below description_below'><li id='field_60_85'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><link rel=\"stylesheet\" href=\"https:\/\/code.jquery.com\/ui\/1.12.1\/themes\/base\/jquery-ui.css\">\n<script\n  src=\"https:\/\/code.jquery.com\/ui\/1.12.0\/jquery-ui.min.js\"\n  integrity=\"sha256-eGE6blurk5sHj+rmkfsGYeKyZx3M4bG+ZlFyA7Kns7E=\"\n  crossorigin=\"anonymous\">\n<\/script>\n<link href=\"https:\/\/cdn.jsdelivr.net\/npm\/select2@4.0.13\/dist\/css\/select2.min.css\" rel=\"stylesheet\" \/>\n<script src=\"https:\/\/cdn.jsdelivr.net\/npm\/select2@4.0.13\/dist\/js\/select2.min.js\"><\/script>\n\n<script type='text\/javascript' src=\"https:\/\/radiologyassist.com\/js\/VirtualConsult_V3\/VirtualConsult_V3.js\"><\/script>\n<\/li><li id='field_60_62'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Virtual Consultation Service<\/h2><\/li><li id='field_60_77'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><p style=\"font-size: 16px;\">You are being scheduled for a <b> consultation<\/b><\/li><li id='field_60_64'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div class=\"Request_Form_Info\">\n<h2>What is a virtual consult?<\/h2>\nIn a virtual consult, a licensed provider will write an imaging order based on a virtual visit. A cirtual consultation does not include a call and does not always allow for a back and forth discussion like a regular consult so you must be detailed and specific with your request.\n<br><br>\n<h2>What are the pros and cons of a virtual consult?<\/h2>\nA virtual consult is faster and lower cost than a traditional consult where a provider meets with a patient in-person. However, it is often not a good choice when the patient needs advice that requires a back and forth discussion.\n<br><br>\n<h2>How long will it take to get a response?<\/h2>\nProviders will respond within 1 business day.\nFor example : a consult submitted at 10am on Monday, will be completed by 5pm Tuesday.\nDo not use this service in case of an emergency.\n<\/div><\/li><li id='field_60_65'  class='gfield CheckBox gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_65'><li class='gchoice_60_65_1'>\n\t\t\t\t\t\t\t\t<input name='input_65.1' type='checkbox'  value='I understand that a provider will write an imaging order without a phone call.'  id='choice_60_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_65_1' id='label_60_65_1'>I understand that a provider will write an imaging order without a phone call.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_78'  class='gfield CheckBox gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_78'><li class='gchoice_60_78_1'>\n\t\t\t\t\t\t\t\t<input name='input_78.1' type='checkbox'  value='I understand that referrals are based on medical necessity guidelines. The medical provider could determine that an alternate type of study is needed.'  id='choice_60_78_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_78_1' id='label_60_78_1'>I understand that referrals are based on medical necessity guidelines. The medical provider could determine that an alternate type of study is needed.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_117'  class='gfield CheckBox gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_117'><li class='gchoice_60_117_1'>\n\t\t\t\t\t\t\t\t<input name='input_117.1' type='checkbox'  value='There is no guarantee that RadiologyAssist can actually schedule the order written.  No refunds will be provided.'  id='choice_60_117_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_117_1' id='label_60_117_1'>There is no guarantee that RadiologyAssist can actually schedule the order written.  No refunds will be provided.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_60_63' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"2\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"2\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_60_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_60_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_60_4'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Patient Information<\/h2><\/li><li id='field_60_3'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Patient Name<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_3'>Please enter exactly as on your id. The name on the order can not be changed once issued.<\/div><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_60_3'>\n                            \n                            <span id='input_60_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_60_3_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_60_3_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_60_3_6_container' class='name_last' >\n                                                    <input type='text' name='input_3.6' id='input_60_3_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_60_3_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_60_7'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_60_7' >Date of birth<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_7'>Please enter exactly as on your id. It can not be changed later.<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_60_7' type='text' value='' class='datepicker medium mdy datepicker_no_icon'    aria-describedby='input_60_7_date_format' \/>\n                            <span id='input_60_7_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_60_7' class='gform_hidden' value='https:\/\/radiologyassist.com\/StagingAvada\/wp-content\/plugins\/gravityforms-2.4.20\/images\/calendar.png'\/><\/li><li id='field_60_100'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Is the patient a minor (under the age of 18)?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_100'><li class='gchoice_60_100_0'><input name='input_100' type='radio' value='Yes'  id='choice_60_100_0'    \/><label for='choice_60_100_0' id='label_60_100_0'>Yes<\/label><\/li><li class='gchoice_60_100_1'><input name='input_100' type='radio' value='No'  id='choice_60_100_1'    \/><label for='choice_60_100_1' id='label_60_100_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_60_99'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Legal Guardian Name<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_99'>For patient under 18, the request must be completed and signed by the legal guardian.<\/div><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_60_99'>\n                            \n                            <span id='input_60_99_3_container' class='name_first' >\n                                                    <input type='text' name='input_99.3' id='input_60_99_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_60_99_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_60_99_6_container' class='name_last' >\n                                                    <input type='text' name='input_99.6' id='input_60_99_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_60_99_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_60_9'  class='gfield gf_right_half gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gender<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_9'><li class='gchoice_60_9_0'><input name='input_9' type='radio' value='Male'  id='choice_60_9_0'    \/><label for='choice_60_9_0' id='label_60_9_0'>Male<\/label><\/li><li class='gchoice_60_9_1'><input name='input_9' type='radio' value='Female'  id='choice_60_9_1'    \/><label for='choice_60_9_1' id='label_60_9_1'>Female<\/label><\/li><\/ul><\/div><\/li><li id='field_60_6'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_60_6' >Phone<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_6'>Provider will call you at this number. Please ensure it is accurate and you are reachable at this number.<\/div><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_60_6' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_60_6\" \/><\/div><\/li><li id='field_60_5'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_5' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_60_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_60_8'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_60_8' >\n                         <span class='ginput_full address_line_1' id='input_60_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_60_8_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_60_8_1' id='input_60_8_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_60_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_60_8_2' value=''   \/>\n                                        <label for='input_60_8_2' id='input_60_8_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_60_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_60_8_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_60_8_3' id='input_60_8_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_60_8_4_container' >\n                                        <select name='input_8.4' id='input_60_8_4'     aria-required=\"true\"><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_60_8_4' id='input_60_8_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_60_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_60_8_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_60_8_5' id='input_60_8_5_label' >Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_60_8_6' value='USAB'\/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_60_118'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\n    color: #961414;\n    background: #f2f2f2;\n    border: 3px solid #961414;\"><b>We are currently unable to provide a virtual consultation in your state.\n<\/b><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_60_69' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"1\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"1\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_60_69' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"3\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"3\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_60_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_60_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_60_113'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_hidden' ><h2 class='gsection_title'>Consultation Type<\/h2><\/li><li id='field_60_60'  class='gfield gf_list_inline field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label'  >Is this a follow up to a previous virtual consultation you completed?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_60'><li class='gchoice_60_60_0'><input name='input_60' type='radio' value='Yes2'  id='choice_60_60_0'    \/><label for='choice_60_60_0' id='label_60_60_0'>Yes<\/label><\/li><li class='gchoice_60_60_1'><input name='input_60' type='radio' value='No' checked='checked' id='choice_60_60_1'    \/><label for='choice_60_60_1' id='label_60_60_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_60_80'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div class=\"Request_Form_Info\">\n<h2>Synchronous Consultation Selected<\/h2>\nSince you need to speak with a provider, we will schedule you for a synchronous consultation. \nYou will receive email instructions with a login to initiate an instant chat with a provider. You will need to upload your reports in the chat and will have 5 days to complete the consult. Do not submit a request until you have your reports ready.\n<br>\n<br>\nThe cost of this follow up consult is $40.\n<br>\n<br>\nRadiologyAssist is unable to obtain reports for you.\n<\/div><\/li><li id='field_60_70'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Requested Imaging Study<\/h2><\/li><li id='field_60_90'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_90'><li class='gchoice_60_90_1'>\n\t\t\t\t\t\t\t\t<input name='input_90.1' type='checkbox'  value='I am unsure what study is needed. Let the provider determine the appropriate imaging study for me'  id='choice_60_90_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_90_1' id='label_60_90_1'>I am unsure what study is needed. Let the provider determine the appropriate imaging study for me<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_94'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_94' >Imaging Studies Requested<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_94[]' id='input_60_94' class='medium gfield_select'  ><option value='As Per Provider Preference' >As Per Provider Preference<\/option><option value='I do not know what study I need' >I do not know what study I need<\/option><option value='MRI - As Per Provider Preference' >MRI - As Per Provider Preference<\/option><option value='CT Scan - As Per Provider Preference' >CT Scan - As Per Provider Preference<\/option><option value='Ultrasound - As Per Provider Preference' >Ultrasound - As Per Provider Preference<\/option><option value='Xray - As Per Provider Preference' >Xray - As Per Provider Preference<\/option><option value='DEXA - As Per Provider Preference' >DEXA - As Per Provider Preference<\/option><option value='74181 - MRI - Abdomen - Without Contrast' >74181 - MRI - Abdomen - Without Contrast<\/option><option value='74183 - MRI - Abdomen - With &amp; Without Contrast' >74183 - MRI - Abdomen - With &amp; Without Contrast<\/option><option value='73221 - MRI - Upper Extremity Joint - Without Contrast' >73221 - MRI - Upper Extremity Joint - Without Contrast<\/option><option value='73223 - MRI - Upper Extremity Joint - With &amp; Without Contrast' >73223 - MRI - Upper Extremity Joint - With &amp; Without Contrast<\/option><option value='73218 - MRI - Upper Extremity Non Joint - Without Contrast' >73218 - MRI - Upper Extremity Non Joint - Without Contrast<\/option><option value='73220 - MRI - Upper Extremity Non Joint - With &amp; Without Contrast' >73220 - MRI - Upper Extremity Non Joint - With &amp; Without Contrast<\/option><option value='73721 - MRI - Lower Extremity Joint - Without Contrast' >73721 - MRI - Lower Extremity Joint - Without Contrast<\/option><option value='73723 - MRI - Lower Extremity Joint - With &amp; Without Contrast' >73723 - MRI - Lower Extremity Joint - With &amp; Without Contrast<\/option><option value='73718 - MRI - Lower Extremity - Without Contrast' >73718 - MRI - Lower Extremity - Without Contrast<\/option><option value='73720 - MRI - Lower Extremity - With &amp; Without Contrast' >73720 - MRI - Lower Extremity - With &amp; Without Contrast<\/option><option value='73721 - MRI - Ankle - Without Contrast' >73721 - MRI - Ankle - Without Contrast<\/option><option value='73723 - MRI - Ankle - With &amp; Without Contrast' >73723 - MRI - Ankle - With &amp; Without Contrast<\/option><option value='&quot;73615, 73722, 27648 - MRI - Ankle - Arthrogram&quot;' >&quot;73615, 73722, 27648 - MRI - Ankle - Arthrogram&quot;<\/option><option value='&quot;73615, 73722, 27648 - MRI - Arthrogram - Ankle (Unilateral)&quot;' >&quot;73615, 73722, 27648 - MRI - Arthrogram - Ankle (Unilateral)&quot;<\/option><option value='&quot;73115, 73222, 25246 - MRI - Arthrogram - Wrist (Unilateral)&quot;' >&quot;73115, 73222, 25246 - MRI - Arthrogram - Wrist (Unilateral)&quot;<\/option><option value='&quot;70336, 77002, 21161 - MRI - Arthrogram - TMJ&quot;' >&quot;70336, 77002, 21161 - MRI - Arthrogram - TMJ&quot;<\/option><option value='&quot;73040, 73222, 23350 - MRI - Arthrogram - Shoulder (Unilateral)&quot;' >&quot;73040, 73222, 23350 - MRI - Arthrogram - Shoulder (Unilateral)&quot;<\/option><option value='&quot;73580, 73722, 27369 - MRI - Arthrogram - Knee (Unilateral)&quot;' >&quot;73580, 73722, 27369 - MRI - Arthrogram - Knee (Unilateral)&quot;<\/option><option value='&quot;73525, 73722, 27093 - MRI - Arthrogram - Hip (Unilateral)&quot;' >&quot;73525, 73722, 27093 - MRI - Arthrogram - Hip (Unilateral)&quot;<\/option><option value='&quot;73085, 73222, 24220 - MRI - Arthrogram - ELbow (Unilateral)&quot;' >&quot;73085, 73222, 24220 - MRI - Arthrogram - ELbow (Unilateral)&quot;<\/option><option value='70551 - MRI - Brain - Without Contrast' >70551 - MRI - Brain - Without Contrast<\/option><option value='70553 - MRI - Brain - With &amp; Without Contrast' >70553 - MRI - Brain - With &amp; Without Contrast<\/option><option value='&quot;70553, 70553 - MRI - Brain with Pituitary - With &amp; Without Contrast&quot;' >&quot;70553, 70553 - MRI - Brain with Pituitary - With &amp; Without Contrast&quot;<\/option><option value='70551 - MRI - Internal Auditory Canal (IAC) - Without Contrast' >70551 - MRI - Internal Auditory Canal (IAC) - Without Contrast<\/option><option value='70553 - MRI - Internal Auditory Canal (IAC) - With &amp; Without Contrast' >70553 - MRI - Internal Auditory Canal (IAC) - With &amp; Without Contrast<\/option><option value='&quot;70553, 70553 - MRI - Brain and Pituitary - With &amp; Without Contrast&quot;' >&quot;70553, 70553 - MRI - Brain and Pituitary - With &amp; Without Contrast&quot;<\/option><option value='77046 - MRI - Breast - Unilateral - Without Contrast' >77046 - MRI - Breast - Unilateral - Without Contrast<\/option><option value='77048 - MRI - Breast - Unilateral - With &amp; Without Contrast' >77048 - MRI - Breast - Unilateral - With &amp; Without Contrast<\/option><option value='77047 - MRI - Breast - Bilateral - Without Contrast' >77047 - MRI - Breast - Bilateral - Without Contrast<\/option><option value='77049 - MRI - Breast - Bilateral - With &amp; Without Contrast' >77049 - MRI - Breast - Bilateral - With &amp; Without Contrast<\/option><option value='72156 - MRI - Cervical Spine - With &amp; Without Contrast' >72156 - MRI - Cervical Spine - With &amp; Without Contrast<\/option><option value='72141 - MRI - Cervical Spine - Without Contrast' >72141 - MRI - Cervical Spine - Without Contrast<\/option><option value='71552 - MRI - Chest\/Thorax - With &amp; Without Contrast' >71552 - MRI - Chest\/Thorax - With &amp; Without Contrast<\/option><option value='71550 - MRI - Chest\/Thorax - Without Contrast' >71550 - MRI - Chest\/Thorax - Without Contrast<\/option><option value='74181 - MRI - Cholangiopancreatography - Without Contrast' >74181 - MRI - Cholangiopancreatography - Without Contrast<\/option><option value='73223 - MRI - Elbow - With &amp; Without Contrast' >73223 - MRI - Elbow - With &amp; Without Contrast<\/option><option value='73221 - MRI - Elbow - Without Contrast' >73221 - MRI - Elbow - Without Contrast<\/option><option value='&quot;73085, 73222, 24220 - MRI - Elbow - Arthrogram&quot;' >&quot;73085, 73222, 24220 - MRI - Elbow - Arthrogram&quot;<\/option><option value='&quot;74183, 72197 - MRI - Enterography - With &amp; Without Contrast&quot;' >&quot;74183, 72197 - MRI - Enterography - With &amp; Without Contrast&quot;<\/option><option value='73720 - MRI - Foot - With &amp; Without Contrast' >73720 - MRI - Foot - With &amp; Without Contrast<\/option><option value='73718 - MRI - Foot - Without Contrast' >73718 - MRI - Foot - Without Contrast<\/option><option value='73218 - MRI - Hand - Without Contrast' >73218 - MRI - Hand - Without Contrast<\/option><option value='73220 - MRI - Hand - With &amp; Without Contrast' >73220 - MRI - Hand - With &amp; Without Contrast<\/option><option value='73218 - MRI - Forearm - Without Contrast' >73218 - MRI - Forearm - Without Contrast<\/option><option value='73220 - MRI - Forearm - With &amp; Without Contrast' >73220 - MRI - Forearm - With &amp; Without Contrast<\/option><option value='73218 - MRI - Humerus - Without Contrast' >73218 - MRI - Humerus - Without Contrast<\/option><option value='73220 - MRI - Humerus - With &amp; Without Contrast' >73220 - MRI - Humerus - With &amp; Without Contrast<\/option><option value='73723 - MRI - Hip - Unilateral - With &amp; Without Contrast' >73723 - MRI - Hip - Unilateral - With &amp; Without Contrast<\/option><option value='73721 - MRI - Hip - Unilateral - Without Contrast' >73721 - MRI - Hip - Unilateral - Without Contrast<\/option><option value='&quot;73723, 73723 - MRI - Hip - Bilateral - With &amp; Without Contrast&quot;' >&quot;73723, 73723 - MRI - Hip - Bilateral - With &amp; Without Contrast&quot;<\/option><option value='&quot;73721, 73721 - MRI - Hip - Bilateral - Without Contrast&quot;' >&quot;73721, 73721 - MRI - Hip - Bilateral - Without Contrast&quot;<\/option><option value='&quot;73525, 73722, 27093 - MRI - Hip - Unilateral - Arthrogram&quot;' >&quot;73525, 73722, 27093 - MRI - Hip - Unilateral - Arthrogram&quot;<\/option><option value='73723 - MRI - Knee - Unilateral - With &amp; Without Contrast' >73723 - MRI - Knee - Unilateral - With &amp; Without Contrast<\/option><option value='73721 - MRI - Knee - Unilateral - Without Contrast' >73721 - MRI - Knee - Unilateral - Without Contrast<\/option><option value='73723 - MRI - Knee (Left) - Unilateral - With &amp; Without Contrast' >73723 - MRI - Knee (Left) - Unilateral - With &amp; Without Contrast<\/option><option value='73721 - MRI - Knee (Left)  - Unilateral - Without Contrast' >73721 - MRI - Knee (Left)  - Unilateral - Without Contrast<\/option><option value='73723 - MRI - Knee (Right) - Unilateral - With &amp; Without Contrast' >73723 - MRI - Knee (Right) - Unilateral - With &amp; Without Contrast<\/option><option value='73721 - MRI - Knee (Right)  - Unilateral - Without Contrast' >73721 - MRI - Knee (Right)  - Unilateral - Without Contrast<\/option><option value='73723 - MRI - Knee (Unspecified) - Unilateral - With &amp; Without Contrast' >73723 - MRI - Knee (Unspecified) - Unilateral - With &amp; Without Contrast<\/option><option value='73721 - MRI - Knee (Unspecified)  - Unilateral - Without Contrast' >73721 - MRI - Knee (Unspecified)  - Unilateral - Without Contrast<\/option><option value='&quot;73723, 73723 - MRI - Knee - Bilateral - With &amp; Without Contrast&quot;' >&quot;73723, 73723 - MRI - Knee - Bilateral - With &amp; Without Contrast&quot;<\/option><option value='&quot;73721, 73723 - MRI - Knee - Bilateral - Without Contrast&quot;' >&quot;73721, 73723 - MRI - Knee - Bilateral - Without Contrast&quot;<\/option><option value='&quot;73580, 73722, 27369 - MRI - Knee - Unilateral - Arthrogram&quot;' >&quot;73580, 73722, 27369 - MRI - Knee - Unilateral - Arthrogram&quot;<\/option><option value='73720 - MRI - Lower Leg - With &amp; Without Contrast' >73720 - MRI - Lower Leg - With &amp; Without Contrast<\/option><option value='73718 - MRI - Lower Leg - Without Contrast' >73718 - MRI - Lower Leg - Without Contrast<\/option><option value='72158 - MRI - Lumbar Spine - With &amp; Without Contrast' >72158 - MRI - Lumbar Spine - With &amp; Without Contrast<\/option><option value='72148 - MRI - Lumbar Spine - Without Contrast' >72148 - MRI - Lumbar Spine - Without Contrast<\/option><option value='70540 - MRI - Orbit \/ Face \/ Neck - Without Contrast' >70540 - MRI - Orbit \/ Face \/ Neck - Without Contrast<\/option><option value='70543 - MRI - Orbit \/ Face \/ Neck - With &amp; Without Contrast' >70543 - MRI - Orbit \/ Face \/ Neck - With &amp; Without Contrast<\/option><option value='70540 - MRI - Face - Without Contrast' >70540 - MRI - Face - Without Contrast<\/option><option value='70543 - MRI - Face - With &amp; Without Contrast' >70543 - MRI - Face - With &amp; Without Contrast<\/option><option value='70540 - MRI - Neck - Without Contrast' >70540 - MRI - Neck - Without Contrast<\/option><option value='70543 - MRI - Neck - With &amp; Without Contrast' >70543 - MRI - Neck - With &amp; Without Contrast<\/option><option value='72197 - MRI - Pelvis - With &amp; Without Contrast' >72197 - MRI - Pelvis - With &amp; Without Contrast<\/option><option value='72195 - MRI - Pelvis - Without Contrast' >72195 - MRI - Pelvis - Without Contrast<\/option><option value='73223 - MRI - Shoulder - With &amp; Without Contrast' >73223 - MRI - Shoulder - With &amp; Without Contrast<\/option><option value='73221 - MRI - Shoulder - Without Contrast' >73221 - MRI - Shoulder - Without Contrast<\/option><option value='&quot;73040, 73222, 23350 - MRI - Shoulder - Arthrogram&quot;' >&quot;73040, 73222, 23350 - MRI - Shoulder - Arthrogram&quot;<\/option><option value='73720 - MRI - Thigh - With &amp; Without Contrast' >73720 - MRI - Thigh - With &amp; Without Contrast<\/option><option value='73718 - MRI - Thigh - Without Contrast' >73718 - MRI - Thigh - Without Contrast<\/option><option value='72157 - MRI - Thoracic Spine - With &amp; Without Contrast' >72157 - MRI - Thoracic Spine - With &amp; Without Contrast<\/option><option value='72146 - MRI - Thoracic Spine - Without Contrast' >72146 - MRI - Thoracic Spine - Without Contrast<\/option><option value='70336 - MRI - TMJ - With &amp; Without Contrast' >70336 - MRI - TMJ - With &amp; Without Contrast<\/option><option value='&quot;70336, 77002, 21161 - MRI - TMJ - Arthrogram&quot;' >&quot;70336, 77002, 21161 - MRI - TMJ - Arthrogram&quot;<\/option><option value='73223 - MRI - Wrist - With &amp; Without Contrast' >73223 - MRI - Wrist - With &amp; Without Contrast<\/option><option value='73221 - MRI - Wrist - Without Contrast' >73221 - MRI - Wrist - Without Contrast<\/option><option value='&quot;73115, 73222, 25246 - MRI - Wrist - Arthrogram&quot;' >&quot;73115, 73222, 25246 - MRI - Wrist - Arthrogram&quot;<\/option><option value='74176 - CT Scan - Abdomen &amp; Pelvis - Without Contrast' >74176 - CT Scan - Abdomen &amp; Pelvis - Without Contrast<\/option><option value='74178 - CT Scan - Abdomen &amp; Pelvis - With &amp; Without Contrast' >74178 - CT Scan - Abdomen &amp; Pelvis - With &amp; Without Contrast<\/option><option value='74174 - CT Scan - Abdomen &amp; Pelvis - Angiogram' >74174 - CT Scan - Abdomen &amp; Pelvis - Angiogram<\/option><option value='74150 - CT Scan - Abdomen - Without Contrast' >74150 - CT Scan - Abdomen - Without Contrast<\/option><option value='74170 - CT Scan - Abdomen - With &amp; Without Contrast' >74170 - CT Scan - Abdomen - With &amp; Without Contrast<\/option><option value='74175 - CT Scan - Abdomen - Angiogram' >74175 - CT Scan - Abdomen - Angiogram<\/option><option value='73700 - CT Scan - Ankle - Without Contrast' >73700 - CT Scan - Ankle - Without Contrast<\/option><option value='73702 - CT Scan - Ankle - With &amp; Without Contrast' >73702 - CT Scan - Ankle - With &amp; Without Contrast<\/option><option value='73706 - CT Scan - Ankle - Angiogram' >73706 - CT Scan - Ankle - Angiogram<\/option><option value='&quot;73701, 77002, 27648 - CT Scan - Ankle - Arthrogram&quot;' >&quot;73701, 77002, 27648 - CT Scan - Ankle - Arthrogram&quot;<\/option><option value='74175 - CT Scan - Angiogram - Abdomen' >74175 - CT Scan - Angiogram - Abdomen<\/option><option value='74174 - CT Scan - Angiogram - Abdomen &amp; Pelvis' >74174 - CT Scan - Angiogram - Abdomen &amp; Pelvis<\/option><option value='70496 - CT Scan - Angiogram - Head \/ Brain' >70496 - CT Scan - Angiogram - Head \/ Brain<\/option><option value='70496 - CT Scan - Angiogram - Brain' >70496 - CT Scan - Angiogram - Brain<\/option><option value='70498 - CT Scan - Angiogram - Carotids' >70498 - CT Scan - Angiogram - Carotids<\/option><option value='71275 - CT Scan - Angiogram - Chest' >71275 - CT Scan - Angiogram - Chest<\/option><option value='75574 - CT Scan - Angiogram - Heart \/ Coronaries' >75574 - CT Scan - Angiogram - Heart \/ Coronaries<\/option><option value='73706 - CT Scan - Angiogram - Lower Extremity' >73706 - CT Scan - Angiogram - Lower Extremity<\/option><option value='70498 - CT Scan - Angiogram - Neck' >70498 - CT Scan - Angiogram - Neck<\/option><option value='72191 - CT Scan - Angiogram - Pelvic' >72191 - CT Scan - Angiogram - Pelvic<\/option><option value='75572 - CT Scan - Angiogram - Pulmonary' >75572 - CT Scan - Angiogram - Pulmonary<\/option><option value='74175 - CT Scan - Angiogram - Renal' >74175 - CT Scan - Angiogram - Renal<\/option><option value='75635 - CT Scan - Angiogram - Run-Offs' >75635 - CT Scan - Angiogram - Run-Offs<\/option><option value='73206 - CT Scan - Angiogram - Upper Extremity' >73206 - CT Scan - Angiogram - Upper Extremity<\/option><option value='70450 - CT Scan - Brain - Without Contrast' >70450 - CT Scan - Brain - Without Contrast<\/option><option value='70460 - CT Scan - Brain - With Contrast' >70460 - CT Scan - Brain - With Contrast<\/option><option value='70470 - CT Scan - Brain - With &amp; Without Contrast' >70470 - CT Scan - Brain - With &amp; Without Contrast<\/option><option value='70496 - CT Scan - Brain - Angiogram' >70496 - CT Scan - Brain - Angiogram<\/option><option value='75571 - CT Scan - Calcium Score - Without Contrast' >75571 - CT Scan - Calcium Score - Without Contrast<\/option><option value='71250 - CT Scan - Chest - Without Contrast' >71250 - CT Scan - Chest - Without Contrast<\/option><option value='71260 - CT Scan - Chest - With Contrast' >71260 - CT Scan - Chest - With Contrast<\/option><option value='71270 - CT Scan - Chest - With &amp; Without Contrast' >71270 - CT Scan - Chest - With &amp; Without Contrast<\/option><option value='71275 - CT Scan - Chest - Angiogram' >71275 - CT Scan - Chest - Angiogram<\/option><option value='72125 - CT Scan - Cervical Spine - Without Contrast' >72125 - CT Scan - Cervical Spine - Without Contrast<\/option><option value='72126 - CT Scan - Cervical Spine - With Contrast' >72126 - CT Scan - Cervical Spine - With Contrast<\/option><option value='72127 - CT Scan - Cervical Spine - With &amp; Without Contrast' >72127 - CT Scan - Cervical Spine - With &amp; Without Contrast<\/option><option value='74177 - CT Scan - Enterography - Without Contrast' >74177 - CT Scan - Enterography - Without Contrast<\/option><option value='70450 - CT Scan - Head - Without Contrast' >70450 - CT Scan - Head - Without Contrast<\/option><option value='70460 - CT Scan - Head - With Contrast' >70460 - CT Scan - Head - With Contrast<\/option><option value='70470 - CT Scan - Head - With &amp; Without Contrast' >70470 - CT Scan - Head - With &amp; Without Contrast<\/option><option value='70496 - CT Scan - Head - Angiogram' >70496 - CT Scan - Head - Angiogram<\/option><option value='73700 - CT Scan - Lower Extremity - Without Contrast' >73700 - CT Scan - Lower Extremity - Without Contrast<\/option><option value='73701 - CT Scan - Lower Extremity - With Contrast' >73701 - CT Scan - Lower Extremity - With Contrast<\/option><option value='73702 - CT Scan - Lower Extremity - With &amp; Without Contrast' >73702 - CT Scan - Lower Extremity - With &amp; Without Contrast<\/option><option value='73706 - CT Scan - Lower Extremity - Angiogram' >73706 - CT Scan - Lower Extremity - Angiogram<\/option><option value='72131 - CT Scan - Lumbar Spine - Without Contrast' >72131 - CT Scan - Lumbar Spine - Without Contrast<\/option><option value='72132 - CT Scan - Lumbar Spine - With Contrast' >72132 - CT Scan - Lumbar Spine - With Contrast<\/option><option value='72133 - CT Scan - Lumbar Spine - With &amp; Without Contrast' >72133 - CT Scan - Lumbar Spine - With &amp; Without Contrast<\/option><option value='70486 - CT Scan - Maxillofacial - Without Contrast' >70486 - CT Scan - Maxillofacial - Without Contrast<\/option><option value='70487 - CT Scan - Maxillofacial - With Contrast' >70487 - CT Scan - Maxillofacial - With Contrast<\/option><option value='70488 - CT Scan - Maxillofacial - With &amp; Without Contrast' >70488 - CT Scan - Maxillofacial - With &amp; Without Contrast<\/option><option value='72192 - CT Scan - Pelvis - Without Contrast' >72192 - CT Scan - Pelvis - Without Contrast<\/option><option value='72193 - CT Scan - Pelvis - With Contrast' >72193 - CT Scan - Pelvis - With Contrast<\/option><option value='72194 - CT Scan - Pelvis - With &amp; Without Contrast' >72194 - CT Scan - Pelvis - With &amp; Without Contrast<\/option><option value='72191 - CT Scan - Pelvis - Angiogram' >72191 - CT Scan - Pelvis - Angiogram<\/option><option value='70490 - CT Scan - Neck - Without Contrast' >70490 - CT Scan - Neck - Without Contrast<\/option><option value='70491 - CT Scan - Neck - With Contrast' >70491 - CT Scan - Neck - With Contrast<\/option><option value='70492 - CT Scan - Neck - With &amp; Without Contrast' >70492 - CT Scan - Neck - With &amp; Without Contrast<\/option><option value='70498 - CT Scan - Neck - Angiogram' >70498 - CT Scan - Neck - Angiogram<\/option><option value='70480 - CT Scan - Orbits \/ Sella \/ Iacs - Without Contrast' >70480 - CT Scan - Orbits \/ Sella \/ Iacs - Without Contrast<\/option><option value='70481 - CT Scan - Orbits \/ Sella \/ Iacs - With Contrast' >70481 - CT Scan - Orbits \/ Sella \/ Iacs - With Contrast<\/option><option value='70482 - CT Scan - Orbits \/ Sella \/ Iacs - With &amp; Without Contrast' >70482 - CT Scan - Orbits \/ Sella \/ Iacs - With &amp; Without Contrast<\/option><option value='70486 - CT Scan - Sinus - Complete Without Contrast' >70486 - CT Scan - Sinus - Complete Without Contrast<\/option><option value='72128 - CT Scan - Thoracic Spine - Without Contrast' >72128 - CT Scan - Thoracic Spine - Without Contrast<\/option><option value='72129 - CT Scan - Thoracic Spine - With Contrast' >72129 - CT Scan - Thoracic Spine - With Contrast<\/option><option value='72130 - CT Scan - Thoracic Spine - With &amp; Without Contrast' >72130 - CT Scan - Thoracic Spine - With &amp; Without Contrast<\/option><option value='73200 - CT Scan - Upper Extremity - Without Contrast' >73200 - CT Scan - Upper Extremity - Without Contrast<\/option><option value='73201 - CT Scan - Upper Extremity - With Contrast' >73201 - CT Scan - Upper Extremity - With Contrast<\/option><option value='73202 - CT Scan - Upper Extremity - With &amp; Without Contrast' >73202 - CT Scan - Upper Extremity - With &amp; Without Contrast<\/option><option value='73206 - CT Scan - Upper Extremity - Angiogram' >73206 - CT Scan - Upper Extremity - Angiogram<\/option><option value='74178 - CT Scan - Urogram - With &amp; Without Contrast' >74178 - CT Scan - Urogram - With &amp; Without Contrast<\/option><option value='G0297 - CT Scan - Lungs - Cancer Screening - Low Dose' >G0297 - CT Scan - Lungs - Cancer Screening - Low Dose<\/option><option value='71271 - CT Scan - Lungs - Cancer Screening - Low Dose' >71271 - CT Scan - Lungs - Cancer Screening - Low Dose<\/option><option value='75571 - CT Scan - Coronary Screening - Low Dose' >75571 - CT Scan - Coronary Screening - Low Dose<\/option><option value='77073 - CT Scan - Scanogram-Leg lengths - Scanogram-Leg lengths' >77073 - CT Scan - Scanogram-Leg lengths - Scanogram-Leg lengths<\/option><option value='76700 - Ultrasound - Abdomen - Complete' >76700 - Ultrasound - Abdomen - Complete<\/option><option value='76705 - Ultrasound - Abdomen - Limited - Single Organ \/ Quadrant or follow up' >76705 - Ultrasound - Abdomen - Limited - Single Organ \/ Quadrant or follow up<\/option><option value='&quot;76700, 76856 - Ultrasound - Abdomen &amp; Pelvis - w\/o Transvaginal&quot;' >&quot;76700, 76856 - Ultrasound - Abdomen &amp; Pelvis - w\/o Transvaginal&quot;<\/option><option value='&quot;76700, 76856, 76830 - Ultrasound - Abdomen &amp; Pelvis - With Transvaginal&quot;' >&quot;76700, 76856, 76830 - Ultrasound - Abdomen &amp; Pelvis - With Transvaginal&quot;<\/option><option value='76882 - Ultrasound - Axilla - Complete' >76882 - Ultrasound - Axilla - Complete<\/option><option value='76641 - Ultrasound - Breast (Unilateral)' >76641 - Ultrasound - Breast (Unilateral)<\/option><option value='7699A - Ultrasound - Buttock - Complete' >7699A - Ultrasound - Buttock - Complete<\/option><option value='93880 - Ultrasound - Carotid - Carotid' >93880 - Ultrasound - Carotid - Carotid<\/option><option value='76604 - Ultrasound - Chest - Pleural Effusion Fluid in Chest or Soft Tissue' >76604 - Ultrasound - Chest - Pleural Effusion Fluid in Chest or Soft Tissue<\/option><option value='76604 - Ultrasound - Chest Wall - Complete' >76604 - Ultrasound - Chest Wall - Complete<\/option><option value='76856 - Ultrasound - Pelvis - Pelvic Complete' >76856 - Ultrasound - Pelvis - Pelvic Complete<\/option><option value='76856 - Ultrasound - Genitalia (Male) - Prostate (Non-transrectal)' >76856 - Ultrasound - Genitalia (Male) - Prostate (Non-transrectal)<\/option><option value='76870 - Ultrasound - Genitalia (Male) - Scrotum and Contents (Testicles)' >76870 - Ultrasound - Genitalia (Male) - Scrotum and Contents (Testicles)<\/option><option value='76882 - Ultrasound - Groin (Hip Groin Region &amp; Peripheral Nerves) - Complete' >76882 - Ultrasound - Groin (Hip Groin Region &amp; Peripheral Nerves) - Complete<\/option><option value='76536 - Ultrasound - Head \/ Neck - Soft Tissues (Thyroid Parathyroid Parotid)' >76536 - Ultrasound - Head \/ Neck - Soft Tissues (Thyroid Parathyroid Parotid)<\/option><option value='76770 - Ultrasound - Kidney \/ Renal - Complete' >76770 - Ultrasound - Kidney \/ Renal - Complete<\/option><option value='93975 - Ultrasound - Doppler - Complete' >93975 - Ultrasound - Doppler - Complete<\/option><option value='93976 - Ultrasound - Doppler - Limited' >93976 - Ultrasound - Doppler - Limited<\/option><option value='76801 - Ultrasound - Ob\/Gyn - 1st Trimester &lt;14 weeks' >76801 - Ultrasound - Ob\/Gyn - 1st Trimester &lt;14 weeks<\/option><option value='76805 - Ultrasound - Ob\/Gyn - 2nd &amp; 3rd Trimester &gt;14weeks' >76805 - Ultrasound - Ob\/Gyn - 2nd &amp; 3rd Trimester &gt;14weeks<\/option><option value='76815 - Ultrasound - Ob\/Gyn - OB Limited (Fetal heartbeat Placental &amp; Fetal Position)' >76815 - Ultrasound - Ob\/Gyn - OB Limited (Fetal heartbeat Placental &amp; Fetal Position)<\/option><option value='76816 - Ultrasound - Ob\/Gyn - OB Follow Up (Re-Evaluate Fetal Size &amp; Organ Sys)' >76816 - Ultrasound - Ob\/Gyn - OB Follow Up (Re-Evaluate Fetal Size &amp; Organ Sys)<\/option><option value='76857 - Ultrasound - Pelvic Wall - Complete' >76857 - Ultrasound - Pelvic Wall - Complete<\/option><option value='76857 - Ultrasound - Pelvis - Bladder Only' >76857 - Ultrasound - Pelvis - Bladder Only<\/option><option value='76830 - Ultrasound - Transvaginal - Transvaginal (Non-Obstetric)' >76830 - Ultrasound - Transvaginal - Transvaginal (Non-Obstetric)<\/option><option value='&quot;76856, 76830 - Ultrasound - Pelvis and Transvaginal - Complete&quot;' >&quot;76856, 76830 - Ultrasound - Pelvis and Transvaginal - Complete&quot;<\/option><option value='&quot;76856, 76830, 93975 - Ultrasound - Pelvis and Transvaginal with Doppler&quot;' >&quot;76856, 76830, 93975 - Ultrasound - Pelvis and Transvaginal with Doppler&quot;<\/option><option value='76800 - Ultrasound - Spine - Spinal Canal &amp; Contents' >76800 - Ultrasound - Spine - Spinal Canal &amp; Contents<\/option><option value='76870 - Ultrasound - Testicular \/ Scrotal - Testicular \/ Scrotal' >76870 - Ultrasound - Testicular \/ Scrotal - Testicular \/ Scrotal<\/option><option value='&quot;76870, 93975 - Ultrasound - Testicular \/ Scrotal with Doppler (Complete)&quot;' >&quot;76870, 93975 - Ultrasound - Testicular \/ Scrotal with Doppler (Complete)&quot;<\/option><option value='&quot;76870, 93976 - Ultrasound - Testicular \/ Scrotal with Doppler (Limited)&quot;' >&quot;76870, 93976 - Ultrasound - Testicular \/ Scrotal with Doppler (Limited)&quot;<\/option><option value='76881 - Ultrasound - Upper &amp; Lower Extremities - Complete' >76881 - Ultrasound - Upper &amp; Lower Extremities - Complete<\/option><option value='93925 - Ultrasound - Arterial - Bilateral' >93925 - Ultrasound - Arterial - Bilateral<\/option><option value='93926 - Ultrasound - Arterial - Unilateral' >93926 - Ultrasound - Arterial - Unilateral<\/option><option value='93971 - Ultrasound - Venous - Unilateral' >93971 - Ultrasound - Venous - Unilateral<\/option><option value='93970 - Ultrasound - Venous - Bilateral' >93970 - Ultrasound - Venous - Bilateral<\/option><option value='76700 - Ultrasound - Liver - Complete' >76700 - Ultrasound - Liver - Complete<\/option><option value='76700 - Ultrasound - Pancreas - Complete' >76700 - Ultrasound - Pancreas - Complete<\/option><option value='76700 - Ultrasound - Aorta - Complete' >76700 - Ultrasound - Aorta - Complete<\/option><option value='76700 - Ultrasound - Galbladder - Complete' >76700 - Ultrasound - Galbladder - Complete<\/option><option value='76857 - Ultrasound - Bladder - Complete' >76857 - Ultrasound - Bladder - Complete<\/option><option value='&quot;76942, 10021 - Ultrasound - Fine Needle Aspiration w\/imag - Complete&quot;' >&quot;76942, 10021 - Ultrasound - Fine Needle Aspiration w\/imag - Complete&quot;<\/option><option value='&quot;76942, 10160 - Ultrasound - Neck Abscess Drainage by needle - Complete&quot;' >&quot;76942, 10160 - Ultrasound - Neck Abscess Drainage by needle - Complete&quot;<\/option><option value='70100 - Xray - Mandible - 3 Views' >70100 - Xray - Mandible - 3 Views<\/option><option value='70110 - Xray - Mandible - 4+ Views' >70110 - Xray - Mandible - 4+ Views<\/option><option value='70120 - Xray - Mastoids - 2 Views' >70120 - Xray - Mastoids - 2 Views<\/option><option value='70130 - Xray - Mastoids - 3 Views' >70130 - Xray - Mastoids - 3 Views<\/option><option value='70140 - Xray - Facial Bones - 2 Views' >70140 - Xray - Facial Bones - 2 Views<\/option><option value='70150 - Xray - Facial Bones - 3 Views' >70150 - Xray - Facial Bones - 3 Views<\/option><option value='70160 - Xray - Nasal Bones - 3 Views' >70160 - Xray - Nasal Bones - 3 Views<\/option><option value='70200 - Xray - Orbits \/ Sella \/ Iacs - 4+ Views' >70200 - Xray - Orbits \/ Sella \/ Iacs - 4+ Views<\/option><option value='70210 - Xray - Sinuses\/ Paranasal - 2 Views' >70210 - Xray - Sinuses\/ Paranasal - 2 Views<\/option><option value='70220 - Xray - Sinuses\/ Paranasal - 3 Views' >70220 - Xray - Sinuses\/ Paranasal - 3 Views<\/option><option value='70250 - Xray - Skull - 3 Views' >70250 - Xray - Skull - 3 Views<\/option><option value='70260 - Xray - Skull - 4+ Views' >70260 - Xray - Skull - 4+ Views<\/option><option value='70330 - Xray - Temporomandibular Joint Open\/Closed Bilateral - 1 View' >70330 - Xray - Temporomandibular Joint Open\/Closed Bilateral - 1 View<\/option><option value='70360 - Xray - Neck Soft Tissue - 1 Views' >70360 - Xray - Neck Soft Tissue - 1 Views<\/option><option value='71045 - Xray - Chest - 1 View' >71045 - Xray - Chest - 1 View<\/option><option value='71046 - Xray - Chest - 2 Views' >71046 - Xray - Chest - 2 Views<\/option><option value='71047 - Xray - Chest - 3 Views' >71047 - Xray - Chest - 3 Views<\/option><option value='71048 - Xray - Chest - 4+ Views' >71048 - Xray - Chest - 4+ Views<\/option><option value='71100 - Xray - Ribs Unilateral - 2 Views' >71100 - Xray - Ribs Unilateral - 2 Views<\/option><option value='71101 - Xray - Ribs Unilateral - 3 Views' >71101 - Xray - Ribs Unilateral - 3 Views<\/option><option value='71110 - Xray - Ribs Bilateral - 3 Views' >71110 - Xray - Ribs Bilateral - 3 Views<\/option><option value='71111 - Xray - Ribs Bilateral - 4+ Views' >71111 - Xray - Ribs Bilateral - 4+ Views<\/option><option value='71120 - Xray - Sternum - 2 Views' >71120 - Xray - Sternum - 2 Views<\/option><option value='71130 - Xray - Sternum - 3 Views' >71130 - Xray - Sternum - 3 Views<\/option><option value='72020 - Xray - Spine Single View Specify Level (Scoliosis) - 1 View' >72020 - Xray - Spine Single View Specify Level (Scoliosis) - 1 View<\/option><option value='72040 - Xray - Cervical Spine - 3 Views' >72040 - Xray - Cervical Spine - 3 Views<\/option><option value='72050 - Xray - Cervical Spine - 4 Views' >72050 - Xray - Cervical Spine - 4 Views<\/option><option value='72052 - Xray - Cervical Spine - Complete' >72052 - Xray - Cervical Spine - Complete<\/option><option value='72070 - Xray - Thoracic - 2 Views' >72070 - Xray - Thoracic - 2 Views<\/option><option value='72072 - Xray - Thoracic - 3 Views' >72072 - Xray - Thoracic - 3 Views<\/option><option value='72074 - Xray - Thoracic - 4 Views' >72074 - Xray - Thoracic - 4 Views<\/option><option value='72080 - Xray - Thoracolumbar Junction - 2 Views' >72080 - Xray - Thoracolumbar Junction - 2 Views<\/option><option value='72081 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 1 View' >72081 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 1 View<\/option><option value='72082 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 2 Views' >72082 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 2 Views<\/option><option value='72082 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 3 Views' >72082 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 3 Views<\/option><option value='72083 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 4 Views' >72083 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 4 Views<\/option><option value='72084 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 6+ Views' >72084 - Xray - Spine Scoliosis Study Incl. Supine &amp; Erect - 6+ Views<\/option><option value='72100 - Xray - Lumbar Spine (Lumbosacral) - 2 Views' >72100 - Xray - Lumbar Spine (Lumbosacral) - 2 Views<\/option><option value='72100 - Xray - Lumbar Spine (Lumbosacral)- 3 Views' >72100 - Xray - Lumbar Spine (Lumbosacral)- 3 Views<\/option><option value='72110 - Xray - Lumbar Spine (Lumbosacral) - 4+ Views' >72110 - Xray - Lumbar Spine (Lumbosacral) - 4+ Views<\/option><option value='72114 - Xray - Lumbar Spine (Lumbosacral) Complete Incl. Bending Views - 4+ Views' >72114 - Xray - Lumbar Spine (Lumbosacral) Complete Incl. Bending Views - 4+ Views<\/option><option value='72120 - Xray - Lumbar Spine (Lumbosacral) Bending Views Only - 2 Views' >72120 - Xray - Lumbar Spine (Lumbosacral) Bending Views Only - 2 Views<\/option><option value='72120 - Xray - Lumbar Spine (Lumbosacral) Bending Views Only - 3 Views' >72120 - Xray - Lumbar Spine (Lumbosacral) Bending Views Only - 3 Views<\/option><option value='72170 - Xray - Pelvis - 1 View' >72170 - Xray - Pelvis - 1 View<\/option><option value='72170 - Xray - Pelvis - 2 Views' >72170 - Xray - Pelvis - 2 Views<\/option><option value='72200 - Xray - Sacroiliac Joints - 2 Views' >72200 - Xray - Sacroiliac Joints - 2 Views<\/option><option value='72202 - Xray - Sacroiliac Joints - 3 Views' >72202 - Xray - Sacroiliac Joints - 3 Views<\/option><option value='72220 - Xray - Sacrum &amp; Coccyx - 2 Views' >72220 - Xray - Sacrum &amp; Coccyx - 2 Views<\/option><option value='73000 - Xray - Clavicle Complete - 1 View' >73000 - Xray - Clavicle Complete - 1 View<\/option><option value='73010 - Xray - Scapula Complete - 2 Views' >73010 - Xray - Scapula Complete - 2 Views<\/option><option value='73020 - Xray - Shoulder - 1 View' >73020 - Xray - Shoulder - 1 View<\/option><option value='73030 - Xray - Shoulder - 2 Views' >73030 - Xray - Shoulder - 2 Views<\/option><option value='73050 - Xray - Acromioclavicular Joint Bilat w\/ or w\/o Weights - Acromioclavicular Joint Bilat w\/ or w\/o Weights' >73050 - Xray - Acromioclavicular Joint Bilat w\/ or w\/o Weights - Acromioclavicular Joint Bilat w\/ or w\/o Weights<\/option><option value='73060 - Xray - Humerus - 3 Views' >73060 - Xray - Humerus - 3 Views<\/option><option value='73070 - Xray - Elbow - 1 View' >73070 - Xray - Elbow - 1 View<\/option><option value='73080 - Xray - Elbow - 2 Views' >73080 - Xray - Elbow - 2 Views<\/option><option value='73090 - Xray - Forearm - 1 View' >73090 - Xray - Forearm - 1 View<\/option><option value='73100 - Xray - Wrist - 2 Views' >73100 - Xray - Wrist - 2 Views<\/option><option value='73110 - Xray - Wrist - 3 Views' >73110 - Xray - Wrist - 3 Views<\/option><option value='73120 - Xray - Hand - 2 Views' >73120 - Xray - Hand - 2 Views<\/option><option value='73130 - Xray - Hand - 3 Views' >73130 - Xray - Hand - 3 Views<\/option><option value='&quot;73120, 73120 - Xray - Hand Bilateral - 2 Views&quot;' >&quot;73120, 73120 - Xray - Hand Bilateral - 2 Views&quot;<\/option><option value='&quot;73130, 73130 - Xray - Hand Bilateral - 3 Views&quot;' >&quot;73130, 73130 - Xray - Hand Bilateral - 3 Views&quot;<\/option><option value='73140 - Xray - Fingers - 1 View' >73140 - Xray - Fingers - 1 View<\/option><option value='73501 - Xray - Hip Unilateral Incl AP of Pelvis - 1 View' >73501 - Xray - Hip Unilateral Incl AP of Pelvis - 1 View<\/option><option value='73502 - Xray - Hip Unilateral Incl AP of Pelvis - 2 Views' >73502 - Xray - Hip Unilateral Incl AP of Pelvis - 2 Views<\/option><option value='73502 - Xray - Hip Unilateral Incl AP of Pelvis - 3 Views' >73502 - Xray - Hip Unilateral Incl AP of Pelvis - 3 Views<\/option><option value='73503 - Xray - Hip Unilateral Incl AP of Pelvis - 4 Views' >73503 - Xray - Hip Unilateral Incl AP of Pelvis - 4 Views<\/option><option value='73521 - Xray - Hip Bilateral Incl. AP of Pelvis - 2 Views' >73521 - Xray - Hip Bilateral Incl. AP of Pelvis - 2 Views<\/option><option value='73522 - Xray - Hip Bilateral Incl. AP of Pelvis - 3 Views' >73522 - Xray - Hip Bilateral Incl. AP of Pelvis - 3 Views<\/option><option value='73522 - Xray - Hip Bilateral Incl. AP of Pelvis - 4 Views' >73522 - Xray - Hip Bilateral Incl. AP of Pelvis - 4 Views<\/option><option value='73523 - Xray - Hip Bilateral Incl. AP of Pelvis - 5 Views' >73523 - Xray - Hip Bilateral Incl. AP of Pelvis - 5 Views<\/option><option value='73551 - Xray - Femur - 1 View' >73551 - Xray - Femur - 1 View<\/option><option value='73552 - Xray - Femur - 2 Views' >73552 - Xray - Femur - 2 Views<\/option><option value='73560 - Xray - Knee Single - 1 or 2 Views' >73560 - Xray - Knee Single - 1 or 2 Views<\/option><option value='73562 - Xray - Knee Single - 3 Views' >73562 - Xray - Knee Single - 3 Views<\/option><option value='73564 - Xray - Knee Single - 4 Views' >73564 - Xray - Knee Single - 4 Views<\/option><option value='&quot;73560, 73560 - Xray - Knee Both - 1 or 2 Views&quot;' >&quot;73560, 73560 - Xray - Knee Both - 1 or 2 Views&quot;<\/option><option value='&quot;73562, 73562 - Xray - Knee Both - 3 Views&quot;' >&quot;73562, 73562 - Xray - Knee Both - 3 Views&quot;<\/option><option value='&quot;73564, 73564 - Xray - Knee Both - 4 Views&quot;' >&quot;73564, 73564 - Xray - Knee Both - 4 Views&quot;<\/option><option value='73590 - Xray - Tibia &amp; Fibula - 2 Views' >73590 - Xray - Tibia &amp; Fibula - 2 Views<\/option><option value='73600 - Xray - Ankle - 2 Views' >73600 - Xray - Ankle - 2 Views<\/option><option value='73610 - Xray - Ankle - 3 Views' >73610 - Xray - Ankle - 3 Views<\/option><option value='73620 - Xray - Foot - 2 Views' >73620 - Xray - Foot - 2 Views<\/option><option value='73630 - Xray - Foot - 3 Views' >73630 - Xray - Foot - 3 Views<\/option><option value='&quot;73620, 73620 - Xray - Foot Bilateral - 2 Views&quot;' >&quot;73620, 73620 - Xray - Foot Bilateral - 2 Views&quot;<\/option><option value='&quot;73630, 73630 - Xray - Foot Bilateral - 3 Views&quot;' >&quot;73630, 73630 - Xray - Foot Bilateral - 3 Views&quot;<\/option><option value='73650 - Xray - Calcaneus or Heel - 2 Views' >73650 - Xray - Calcaneus or Heel - 2 Views<\/option><option value='73660 - Xray - Toe(s) - 2 Views' >73660 - Xray - Toe(s) - 2 Views<\/option><option value='74018 - Xray - Abdomen - 1 View' >74018 - Xray - Abdomen - 1 View<\/option><option value='74019 - Xray - Abdomen - 2 Views' >74019 - Xray - Abdomen - 2 Views<\/option><option value='74021 - Xray - Abdomen - 3+ Views' >74021 - Xray - Abdomen - 3+ Views<\/option><option value='74022 - Xray - Abdomen - Abdomen Complete Acute Abdomen Series 1 Chest View' >74022 - Xray - Abdomen - Abdomen Complete Acute Abdomen Series 1 Chest View<\/option><option value='77072 - Xray - Bone &amp; Joints - Bone Age Studies' >77072 - Xray - Bone &amp; Joints - Bone Age Studies<\/option><option value='77073 - Xray - Bone &amp; Joints - Bone Length Studies (Scanogram \/ Orthoroentgenogram)' >77073 - Xray - Bone &amp; Joints - Bone Length Studies (Scanogram \/ Orthoroentgenogram)<\/option><option value='77075 - Xray - Bone &amp; Joints - Bone Survey' >77075 - Xray - Bone &amp; Joints - Bone Survey<\/option><option value='74240 - Xray - Upper GI Tract - w\/o KUB' >74240 - Xray - Upper GI Tract - w\/o KUB<\/option><option value='74241 - Xray - Upper GI Tract - with KUB' >74241 - Xray - Upper GI Tract - with KUB<\/option><option value='74245 - Xray - Upper GI Tract - with small intestine' >74245 - Xray - Upper GI Tract - with small intestine<\/option><option value='74247 - Xray - Upper GI Tract - Contrast with KUB' >74247 - Xray - Upper GI Tract - Contrast with KUB<\/option><option value='74246 - Xray - Upper GI Tract - Contrast w\/o KUB' >74246 - Xray - Upper GI Tract - Contrast w\/o KUB<\/option><option value='74175 - CTA - Angiogram Abdomen - With &amp; Without Contrast' >74175 - CTA - Angiogram Abdomen - With &amp; Without Contrast<\/option><option value='74174 - CTA - Angiogram Abdomen &amp; Pelvis - With &amp; Without Contrast' >74174 - CTA - Angiogram Abdomen &amp; Pelvis - With &amp; Without Contrast<\/option><option value='70496 - CTA - Angiogram Head \/ Brain - With &amp; Without Contrast' >70496 - CTA - Angiogram Head \/ Brain - With &amp; Without Contrast<\/option><option value='70498 - CTA - Angiogram Carotids - With &amp; Without Contrast' >70498 - CTA - Angiogram Carotids - With &amp; Without Contrast<\/option><option value='71275 - CTA - Angiogram Chest - With &amp; Without Contrast' >71275 - CTA - Angiogram Chest - With &amp; Without Contrast<\/option><option value='75574 - CTA - Angiogram Heart \/ Coronaries - Angiogram Heart \/ Coronaries' >75574 - CTA - Angiogram Heart \/ Coronaries - Angiogram Heart \/ Coronaries<\/option><option value='73706 - CTA - Angiogram Lower Extremity - Angiogram Lower Extremity' >73706 - CTA - Angiogram Lower Extremity - Angiogram Lower Extremity<\/option><option value='70498 - CTA - Angiogram Neck - Angiogram Neck' >70498 - CTA - Angiogram Neck - Angiogram Neck<\/option><option value='72191 - CTA - Angiogram Pelvic - Angiogram Pelvic' >72191 - CTA - Angiogram Pelvic - Angiogram Pelvic<\/option><option value='75572 - CTA - Angiogram Pulmonary - Angiogram Pulmonary' >75572 - CTA - Angiogram Pulmonary - Angiogram Pulmonary<\/option><option value='74175 - CTA - Angiogram Renal - With &amp; Without Contrast' >74175 - CTA - Angiogram Renal - With &amp; Without Contrast<\/option><option value='75635 - CTA - Angiogram Run-Offs - With &amp; Without Contrast' >75635 - CTA - Angiogram Run-Offs - With &amp; Without Contrast<\/option><option value='73206 - CTA - Angiogram Upper Extremities - Angiogram Upper Extremities' >73206 - CTA - Angiogram Upper Extremities - Angiogram Upper Extremities<\/option><option value='74185 - MRA - Abdomen Angio - Abdomen' >74185 - MRA - Abdomen Angio - Abdomen<\/option><option value='71555 - MRA - Chest \/ Thorax Angio - Chest \/ Thorax' >71555 - MRA - Chest \/ Thorax Angio - Chest \/ Thorax<\/option><option value='70546 - MRA - Head \/ Brain Angio - With &amp; Without Contrast' >70546 - MRA - Head \/ Brain Angio - With &amp; Without Contrast<\/option><option value='70545 - MRA - Head \/ Brain Angio - With Contrast' >70545 - MRA - Head \/ Brain Angio - With Contrast<\/option><option value='70544 - MRA - Head \/ Brain Angio - Without Contrast' >70544 - MRA - Head \/ Brain Angio - Without Contrast<\/option><option value='73725 - MRA - Lower Extremity Angio - Lower Extremity' >73725 - MRA - Lower Extremity Angio - Lower Extremity<\/option><option value='70549 - MRA - Neck \/ Carotid Angio - With &amp; Without Contrast' >70549 - MRA - Neck \/ Carotid Angio - With &amp; Without Contrast<\/option><option value='70548 - MRA - Neck \/ Carotid Angio - With Contrast' >70548 - MRA - Neck \/ Carotid Angio - With Contrast<\/option><option value='70547 - MRA - Neck \/ Carotid Angio - Without Contrast' >70547 - MRA - Neck \/ Carotid Angio - Without Contrast<\/option><option value='72198 - MRA - Pelvis Angio - Pelvis' >72198 - MRA - Pelvis Angio - Pelvis<\/option><option value='72159 - MRA - Spine \/ Spinal Canal Angio - Spine' >72159 - MRA - Spine \/ Spinal Canal Angio - Spine<\/option><option value='73225 - MRA - Upper Extremity Angio - Upper Extremity' >73225 - MRA - Upper Extremity Angio - Upper Extremity<\/option><option value='74262 - Virtual Colonoscopy - Virtual Colonoscopy Diagnostic - With Contrast' >74262 - Virtual Colonoscopy - Virtual Colonoscopy Diagnostic - With Contrast<\/option><option value='74261 - Virtual Colonoscopy - Virtual Colonoscopy Diagnostic - Without Contrast' >74261 - Virtual Colonoscopy - Virtual Colonoscopy Diagnostic - Without Contrast<\/option><option value='&quot;77067, 77063 - Screening Mammogram&quot;' >&quot;77067, 77063 - Screening Mammogram&quot;<\/option><option value='&quot;77065, 76641 - Diagnostic Mammogram with Breast Ultrasound if needed (Unilateral)&quot;' >&quot;77065, 76641 - Diagnostic Mammogram with Breast Ultrasound if needed (Unilateral)&quot;<\/option><option value='&quot;77066, 76641, 76641 - Diagnostic Mammogram with Breast Ultrasound if needed (Bilateral)&quot;' >&quot;77066, 76641, 76641 - Diagnostic Mammogram with Breast Ultrasound if needed (Bilateral)&quot;<\/option><option value='77080 - DEXA - Bone Density \/ DEXA - Bone Density \/ DEXA' >77080 - DEXA - Bone Density \/ DEXA - Bone Density \/ DEXA<\/option><option value='74181 - MRCP (Abdomen, Liver, Pancreas)' >74181 - MRCP (Abdomen, Liver, Pancreas)<\/option><option value='' ><\/option><\/select><\/div><\/li><li id='field_60_95'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\n    color: #961414;\n    background: #f2f2f2;\n    border: 3px solid #961414;\"><b>Select your best guess or enter \"As Per Provider Preference\" under Imaging Studies Requested.<\/b><\/div><\/li><li id='field_60_81'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_60_81' >Any special protocols or notes for the studies selected?<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_60_81' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_60_98'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >For lateral studies, which side?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_98'><li class='gchoice_60_98_0'><input name='input_98' type='radio' value='Left'  id='choice_60_98_0'    \/><label for='choice_60_98_0' id='label_60_98_0'>Left<\/label><\/li><li class='gchoice_60_98_1'><input name='input_98' type='radio' value='Right'  id='choice_60_98_1'    \/><label for='choice_60_98_1' id='label_60_98_1'>Right<\/label><\/li><li class='gchoice_60_98_2'><input name='input_98' type='radio' value='Both (Bilateral)'  id='choice_60_98_2'    \/><label for='choice_60_98_2' id='label_60_98_2'>Both (Bilateral)<\/label><\/li><li class='gchoice_60_98_3'><input name='input_98' type='radio' value='N\/A'  id='choice_60_98_3'    \/><label for='choice_60_98_3' id='label_60_98_3'>N\/A<\/label><\/li><\/ul><\/div><\/li><li id='field_60_75'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Reason For Study<\/h2><\/li><li id='field_60_74'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_74' >Please provide a detailed explanation about the reason for the request<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_74' id='input_60_74' class='textarea medium'  aria-describedby=\"gfield_description_60_74\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_60_74'>Note : Please be as detailed as possible. The provider will make a medical decision based on your written narrative. Also please include any pertinent information about why the study you are asking for is appropriate.<\/div><\/li><li id='field_60_101'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Follow Up<\/h2><\/li><li id='field_60_103'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >What are your plans for follow up?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_103'><li class='gchoice_60_103_0'><input name='input_103' type='radio' value='I will follow up with my own provider'  id='choice_60_103_0'    \/><label for='choice_60_103_0' id='label_60_103_0'>I will follow up with my own provider<\/label><\/li><\/ul><\/div><\/li><li id='field_60_109'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\n    color: #961414;\n    background: #f2f2f2;\n    border: 3px solid #961414;\"><b>Providers may be less inclined to order complex studies if you do not have a plan in place for follow up.<\/b><\/div><\/li><li id='field_60_114'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\n    color: #961414;\n    background: #f2f2f2;\n    border: 3px solid #961414;\"><b>Great! The cost of a follow up virtual consultation appointment is $40. You can request it using this same form once your reports arrive.<\/b><\/div><\/li><li id='field_60_106'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_106' >Provider Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_60_106' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_60_107'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><link href='https:\/\/clinicaltables.nlm.nih.gov\/autocomplete-lhc-versions\/17.0.2\/autocomplete-lhc.min.css' rel=\"stylesheet\">\n<script src='https:\/\/clinicaltables.nlm.nih.gov\/autocomplete-lhc-versions\/17.0.2\/autocomplete-lhc.min.js'><\/script>\n<script>\nnew Def.Autocompleter.Search(\n  'input_60_106',\n  'https:\/\/clinicaltables.nlm.nih.gov\/api\/npi_idv\/v3\/search?df=name.full,NPI,provider_type,addr_practice.full,addr_practice.fax',\n  {tableFormat: true, valueCols: [0, 1],\n    colHeaders: ['Name', 'NPI', 'Type', 'Practice Address','Fax']\n  });\n\n<\/script><\/li><li id='field_60_111'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\"> <\/div><\/li><li id='field_60_105'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label'  ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_105'><li class='gchoice_60_105_1'>\n\t\t\t\t\t\t\t\t<input name='input_105.1' type='checkbox'  value='I understand that the ordering physician does not have a way of knowing whether an ordered study is scheduled or its outcome.'  id='choice_60_105_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_105_1' id='label_60_105_1'>I understand that the ordering physician does not have a way of knowing whether an ordered study is scheduled or its outcome.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_108'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Other Questions<\/h2><\/li><li id='field_60_67'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you requesting a PET Scan?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_67'><li class='gchoice_60_67_0'><input name='input_67' type='radio' value='Yes'  id='choice_60_67_0'    \/><label for='choice_60_67_0' id='label_60_67_0'>Yes<\/label><\/li><li class='gchoice_60_67_1'><input name='input_67' type='radio' value='No'  id='choice_60_67_1'    \/><label for='choice_60_67_1' id='label_60_67_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_60_66'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\n    color: #961414;\n    background: #f2f2f2;\n    border: 3px solid #961414;\"><b>STOP! PET Scans can not be ordered via our virtual consultation service. PET Scans are an advanced study that require the patient to be under the care of a physician.<\/b><\/div><\/li><li id='field_60_96'  class='gfield gf_list_inline gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you requesting a full body scan?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_60_96'><li class='gchoice_60_96_0'><input name='input_96' type='radio' value='Yes'  id='choice_60_96_0'    \/><label for='choice_60_96_0' id='label_60_96_0'>Yes<\/label><\/li><li class='gchoice_60_96_1'><input name='input_96' type='radio' value='No'  id='choice_60_96_1'    \/><label for='choice_60_96_1' id='label_60_96_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_60_97'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><div style=\"    padding: 20px;\n    color: #961414;\n    background: #f2f2f2;\n    border: 3px solid #961414;\"><b>STOP! Full body scans can not be ordered via our virtual consultation service. These scans require the patient to be under the care of a primary care physician.<\/b><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_60_44' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"2\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"2\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_60_44' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"4\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"4\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_60_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_60_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_60_10'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Medical Information<\/h2><\/li><li id='field_60_25'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any of these allergies?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_25'><li class='gchoice_60_25_1'>\n\t\t\t\t\t\t\t\t<input name='input_25.1' type='checkbox'  value='Radiation'  id='choice_60_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_25_1' id='label_60_25_1'>Radiation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_25_2'>\n\t\t\t\t\t\t\t\t<input name='input_25.2' type='checkbox'  value='Contrast'  id='choice_60_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_25_2' id='label_60_25_2'>Contrast<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_25_3'>\n\t\t\t\t\t\t\t\t<input name='input_25.3' type='checkbox'  value='Dye'  id='choice_60_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_25_3' id='label_60_25_3'>Dye<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_25_4'>\n\t\t\t\t\t\t\t\t<input name='input_25.4' type='checkbox'  value='None'  id='choice_60_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_25_4' id='label_60_25_4'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_28'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Which of these apply to you?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_28'><li class='gchoice_60_28_1'>\n\t\t\t\t\t\t\t\t<input name='input_28.1' type='checkbox'  value='I take metformin'  id='choice_60_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_28_1' id='label_60_28_1'>I take metformin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_28_2'>\n\t\t\t\t\t\t\t\t<input name='input_28.2' type='checkbox'  value='I have a kidney disease'  id='choice_60_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_28_2' id='label_60_28_2'>I have a kidney disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_28_3'>\n\t\t\t\t\t\t\t\t<input name='input_28.3' type='checkbox'  value='I take NSAIDs such as ibuprofen, aleve, advil regularly'  id='choice_60_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_28_3' id='label_60_28_3'>I take NSAIDs such as ibuprofen, aleve, advil regularly<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_28_4'>\n\t\t\t\t\t\t\t\t<input name='input_28.4' type='checkbox'  value='Pregnant'  id='choice_60_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_28_4' id='label_60_28_4'>Pregnant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_28_5'>\n\t\t\t\t\t\t\t\t<input name='input_28.5' type='checkbox'  value='Breastfeeding'  id='choice_60_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_28_5' id='label_60_28_5'>Breastfeeding<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_28_6'>\n\t\t\t\t\t\t\t\t<input name='input_28.6' type='checkbox'  value='None'  id='choice_60_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_28_6' id='label_60_28_6'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_29'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Select if you have any of these implanted devices<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_29'><li class='gchoice_60_29_1'>\n\t\t\t\t\t\t\t\t<input name='input_29.1' type='checkbox'  value='Heart pacemakers'  id='choice_60_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_1' id='label_60_29_1'>Heart pacemakers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_2'>\n\t\t\t\t\t\t\t\t<input name='input_29.2' type='checkbox'  value='Insulin pumps'  id='choice_60_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_2' id='label_60_29_2'>Insulin pumps<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_3'>\n\t\t\t\t\t\t\t\t<input name='input_29.3' type='checkbox'  value='Implanted hearing aids'  id='choice_60_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_3' id='label_60_29_3'>Implanted hearing aids<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_4'>\n\t\t\t\t\t\t\t\t<input name='input_29.4' type='checkbox'  value='Neurostimulators'  id='choice_60_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_4' id='label_60_29_4'>Neurostimulators<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_5'>\n\t\t\t\t\t\t\t\t<input name='input_29.5' type='checkbox'  value='Brain metal clips'  id='choice_60_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_5' id='label_60_29_5'>Brain metal clips<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_6'>\n\t\t\t\t\t\t\t\t<input name='input_29.6' type='checkbox'  value='Metal bone replacement'  id='choice_60_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_6' id='label_60_29_6'>Metal bone replacement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_7'>\n\t\t\t\t\t\t\t\t<input name='input_29.7' type='checkbox'  value='Others'  id='choice_60_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_7' id='label_60_29_7'>Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_60_29_8'>\n\t\t\t\t\t\t\t\t<input name='input_29.8' type='checkbox'  value='No implanted devices'  id='choice_60_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_29_8' id='label_60_29_8'>No implanted devices<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_60_24'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_60_24' >Current medications, including over the counter drugs<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_24'>Answer none if not applicable<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_60_24' class='textarea medium'  aria-describedby=\"gfield_description_60_24\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_60_27'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_60_27' >Are you allergic to any medications?<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_27'>Answer none if not applicable<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_60_27' class='textarea medium'  aria-describedby=\"gfield_description_60_27\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_60_30'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_30' >Any additional comments for the provider<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_60_30' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_60_76'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Consent<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_76.1' id='input_60_76_1' type='checkbox' value='1'  aria-describedby='gfield_consent_description_60_76' aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_60_76_1' >I agree to the informed consent<\/label><input type='hidden' name='input_76.2' value='I agree to the informed consent' class='gform_hidden' \/><input type='hidden' name='input_76.3' value='4' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_60_76'>I certify that the information I provided is complete, accurate and up-to-date to the best of my knowledge.  I understand that incomplete, inaccurate or false information could result in harm from misdiagnosis and inappropriate treatment.<br \/>\n<br \/>\nBy continuing, I certify that I read (or had it read to me), and agree with your Informed Consent Agreement, Terms of Use and Privacy Policy, and that I am at least 18 years of age.  I further understand that the telehealth provider who will see me in consultation is an independent healthcare professional who will abide by the best practice guidelines and all laws and regulations of the state medical board, and has no financial or other incentives to order any tests.  Therefore, he\/she may agree with the requested test if it is medically reasonable, suggest a different test, or not order any test if the request is not supported by your medical history. <\/div><\/li><li id='field_60_59'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Consent<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_59.1' id='input_60_59_1' type='checkbox' value='1'  aria-describedby='gfield_consent_description_60_59' aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_60_59_1' >I understand and agree to the following terms and limitations<\/label><input type='hidden' name='input_59.2' value='I understand and agree to the following terms and limitations' class='gform_hidden' \/><input type='hidden' name='input_59.3' value='4' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_60_59'>This service has the following terms and limitations :<br \/>\n<br><br \/>\n1. RadiologyAssist uses a third party tele-health service to provide consults. It does not employ or have any control over the providers actions or medical opinion.<br \/>\n<br><br \/>\n2. Providers make referrals based on medical necessity guidelines. They could determine that an alternate type of study is needed or that imaging is not warranted at all. Your payment is for the consult and not its outcome. RadiologyAssist does not provide refunds for an unsatisfactory outcome.<br \/>\n<br><br \/>\n3. RadiologyAssist makes no warranties that it is actually able to provide or schedule the imaging for an order written by the provider. <br \/>\n<br><br \/>\n4. Your payment is for the service of consulting a medical professional. The payment does not include any implied guarantee that an order will be written or that RadiologyAssist will be able to schedule services recommended on any order that is written.<br \/>\n<br><br \/>\n5. Any orders written as a result of a consult from this service are the property of the patient and can be used at any medical center including non-RadiologyAssist participating centers.<br \/>\n<br><br \/>\n6. While we state usual turn around times, we do not guarantee any particular time-frame. If your need is urgent, please visit an ER. You may cancel your consultation request prior to receiving your consult at any time for a full refund. Once a consultation is completed, no refunds can be provided for any reason.<br \/>\n<br><br \/>\n7. Referrals are issued based on the information provided by the patient. It is the patient's responsibility to review the written referral for accuracy before proceeding with scheduling any appointments. The issuing party or RadiologyAssist shall not be liable for any errors or omissions resulting from inaccurate or incomplete information provided by the patient.<\/div><\/li><li id='field_60_34'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Please certify<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_60_34'><li class='gchoice_60_34_1'>\n\t\t\t\t\t\t\t\t<input name='input_34.1' type='checkbox'  value='I certify that the information I provided is complete, accurate and up-to-date to the best of my knowledge. I understand that an incomplete, inaccurate and false information puts me at a harmful risk of misdiagnosis and inappropriate treatment. I also certify I have no cognitive impairment and am capable of making a sound medical decision'  id='choice_60_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_60_34_1' id='label_60_34_1'>I certify that the information I provided is complete, accurate and up-to-date to the best of my knowledge. I understand that an incomplete, inaccurate and false information puts me at a harmful risk of misdiagnosis and inappropriate treatment. I also certify I have no cognitive impairment and am capable of making a sound medical decision<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_60_45' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"3\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"3\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_60_45' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_60\").val(\"5\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_60\").val(\"5\");  jQuery(\"#gform_60\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_60_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_60_5' class='gform_fields top_label form_sublabel_below description_below'><li id='field_60_37'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Payment<\/h2><\/li><li id='field_60_38'  class='gfield gf_invisible gfield_price gfield_price_60_38 gfield_product_60_38 field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_38_1' >Virtual Consultation<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_38.1' value='Virtual Consultation' class='gform_hidden' \/>\n\t\t\t\t\t<span class='ginput_product_price_label'>Price:<\/span> <span class='ginput_product_price' id='input_60_38'>$40.00<\/span>\n\t\t\t\t\t<input type='hidden' name='input_38.2' id='ginput_base_price_60_38' class='gform_hidden' value='$40.00'\/>\n\t\t\t\t\t<input type='hidden' name='input_38.3' value='1' class='ginput_quantity_60_38 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id='field_60_115'  class='gfield gf_invisible gfield_price gfield_price_60_115 gfield_product_60_115 field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_115_1' >Async Consultation<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_115.1' value='Async Consultation' class='gform_hidden' \/>\n\t\t\t\t\t<span class='ginput_product_price_label'>Price:<\/span> <span class='ginput_product_price' id='input_60_115'>$0.00<\/span>\n\t\t\t\t\t<input type='hidden' name='input_115.2' id='ginput_base_price_60_115' class='gform_hidden' value='$0.00'\/>\n\t\t\t\t\t<input type='hidden' name='input_115.3' value='1' class='ginput_quantity_60_115 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id='field_60_39'  class='gfield gfield_price gfield_price_60_ gfield_total gfield_total_60_ field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_60_39' >Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t<span class='ginput_total ginput_total_60' aria-live='polite'>$0.00<\/span>\n\t\t\t\t\t\t<input type='hidden' name='input_39' id='input_60_39' class='gform_hidden'\/>\n\t\t\t\t\t<\/div><\/li><li id='field_60_36'  class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_60_36_1' >Credit Card<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_60_36'>Only Mastercard, Visa and Discover accepted<\/div><div class='ginput_complex ginput_container ginput_container_creditcard' id='input_60_36'><span class='ginput_full' id='input_60_36_1_container' >\n                                    <div class='gform_card_icon_container gform_card_icon_style1'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><\/div>\n                                    <input type='text' name='input_36.1' id='input_60_36_1' value=''   onchange='gformMatchCard(\"input_60_36_1\");' onkeyup='gformMatchCard(\"input_60_36_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' \/>\n                                    <label for='input_60_36_1' id='input_60_36_1_label' >Card Number<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras' id='input_60_36_2_container'>\n                                            <span class='ginput_cardinfo_left' id='input_60_36_2_cardinfo_left'>\n                                                <span class='ginput_card_expiration_container ginput_card_field'>\n                                                    <select name='input_36.2[]' id='input_60_36_2_month'   class='ginput_card_expiration ginput_card_expiration_month'>\n                                                        <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                    <\/select>\n                                                    <select name='input_36.2[]' id='input_60_36_2_year'   class='ginput_card_expiration ginput_card_expiration_year'>\n                                                    <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                    <\/select>\n                                                    <label for='input_60_36_2_month' >Expiration Date<\/label>\n                                                <\/span>\n                                            <\/span><span class='ginput_cardinfo_right' id='input_60_36_2_cardinfo_right'>\n                                                <input type='text' name='input_36.3' id='input_60_36_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_60_36_3' >Security Code<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full' id='input_60_36_5_container'>\n                                            <input type='text' name='input_36.5' id='input_60_36_5' value=''   \/>\n                                            <label for='input_60_36_5' id='input_60_36_5_label' >Cardholder Name<\/label>\n                                        <\/span> <\/div><\/li><li id='field_60_40'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Billing Address<span class='gfield_required'>*<\/span><\/label>    <div id='input_60_40_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_60_40_copy_values_activated' class='copy_values_activated' value='1' name='input_40_copy_values_activated'  \/>\n                                        <label for='input_60_40_copy_values_activated' id='input_60_40_copy_values_option_label' class='copy_values_option_label inline'>Same as patient address<\/label>\n                                    <\/div>\n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_60_40' >\n                         <span class='ginput_full address_line_1' id='input_60_40_1_container' >\n                                        <input type='text' name='input_40.1' id='input_60_40_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_60_40_1' id='input_60_40_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_60_40_2_container' >\n                                        <input type='text' name='input_40.2' id='input_60_40_2' value=''   \/>\n                                        <label for='input_60_40_2' id='input_60_40_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_60_40_3_container' >\n                                    <input type='text' name='input_40.3' id='input_60_40_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_60_40_3' id='input_60_40_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_60_40_4_container' >\n                                        <input type='text' name='input_40.4' id='input_60_40_4' value=''      aria-required=\"true\"\/>\n                                        <label for='input_60_40_4' id='input_60_40_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_60_40_5_container' >\n                                    <input type='text' name='input_40.5' id='input_60_40_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_60_40_5' id='input_60_40_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_60_40_6_container' >\n                                        <select name='input_40.6' id='input_60_40_6'   aria-required=\"true\"><option value='' selected='selected'><\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CG' >Congo, Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini (Swaziland)<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macau<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State 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Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen Islands<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' 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