Name

Phone

E-Mail

Ordering Physician

Type of Scan

Date

Appointment Time

Date of Birth

Age

Social Security#

Height

Weight

Male
Female

Any History of Cancer?     Yes No

If Yes, please list all procedures and dates.

MRI is simple, safe and painless. However, because we use strong magnets during the procedure, metal objects in your body may be hazardous or cause interference. Please provide us with this important information before entering the MRI department.

Pacemaker/Valve Implanted electrical device Metal in Eyes Ear/Cochlear implant Neurostimulators Tissue Expander Brain/aneurysm clips Stents Braces Metal fragments or shrapnel Magnetic dental implants Orthopedic Joints / Screws Filters or wire blood vessels

If known, please give name and date(s) of implant

Are you Pregnant? YesNo

Are you breastfeeding? YesNo

Are your injuries related to (check one):

Auto Accident/ Slip & fall / Worker's comp?

Date of injury

Attorney's name

Reason for Exam

I have read the above information and found it to be correct to the best of my knowledge.

YesNo

Patient Name

Date