Partners

Radiology & Procedure Scheduling

These service request forms and information are provided for use by UTMB-affiliated physicians, their office representatives and other care providers who wish to schedule services at UTMB.

Radiology
Radiology/Imaging Orders and Uploads

The Radiology Order Form may be used to request radiology and imaging services across the UTMB Health system. You may 1) print a blank copy of the form, fill in and fax; or 2) fill the form online, print and fax. Please remember to sign either option and fax to the number where service is being requested. A UTMB staff member will follow up with you promptly.

Radiology FAX numbers:
    > Clear Lake: (832) 730-4486
    > League City: (281) 309-0259
    > Galveston: (409) 747-2850
    > Angleton Danbury: (979) 849-1292

To upload and share medical images taken elsewhere to UTMB, use the ImageShare tool.    

Radiology/Imaging Order Form Non-UTMB Study Upload Non-UTMB Study User Guide

Surgical Room
Surgical Booking and Order Form

UTMB Health Clear Lake Campus

This surgical case request form must be completed for all elective cases. Procedures with a preauthorization must be scheduled 24 hours in advance of the requested date/time; procedures without a preauthorization must be scheduled 7 business days in advance. Please ensure all insurance information is provided for all patients with preauthorized services.

    > Please call (832) 632-7272 with questions regarding surgical booking.
    > FAX completed forms to (832) 632-9274

Surgical Order Form Pre-Procedure Patient Info

Cath, heart
Heart Center Booking and Order Form

Cardiac Cath, Peripheral Cath, Electrophysiology, PPM/ICD Implant

UTMB Health Clear Lake Campus

Procedures with a preauthorization must be scheduled 24 hours in advance of the requested date/time; procedures without a preauthorization must be scheduled 7 business days in advance. Please ensure all insurance information is provided for all patients with preauthorized services.

    > To schedule a case, please call 832-632-7158
    > FAX completed forms to (832) 632-9336

Heart Center Order Form Pre-Procedure Patient Info

Veins
ECHO/Vascular Imaging Scheduling Form

Echocardiology, Stress, and Vascular Imaging

UTMB Health Clear Lake Campus

Procedures with a preauthorization must be scheduled 24 hours in advance of the requested date/time; procedures without a preauthorization must be scheduled 7 business days in advance. Please ensure all insurance information is provided for all patients with preauthorized services.

    > To schedule, please call (832) 632-7158
    > FAX completed forms to (832) 632-9336

ECHO/Vascular Imaging Form