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MRI Request and Screening Form

Your referring physician can simply fill out this requisition form online, print, sign and mail, scan or fax the form to us.


PART 1: PATIENT AND PHYSICIAN INFORMATION

M     F
 
WCB RCMP PATIENT
OTHER 
   

 

REFERRING PHYSICIAN

 

PART 2 MEDICAL HISTORY QUESTIONNAIRE


Brain
C-spine*
SI joints		 Orbits
T-spine*
Neck (soft tissue)		 Sella
L-spine*
Brachial Plexus		 IAC
Sacrum

 

TM joints (bilateral)
Hand or Finger**
Foot or Toes**		 Shoulder**
Hip**		 Elbow**
Knee**		 Wrist**
Ankle**

 

Adrenals
Kidneys		 Liver
Pelvis		 MRCP Pancreas
Circle of Willis Carotids MRV Renal MRA



 

PART 3 PATIENT SCREENING INFORMATION

**FOR PATIENT SAFETY, THE PATIENT CANNOT BE SCHEDULED UNTIL THE FOLLOWING QUESTIONS HAVE BEEN ANSWERED**

Yes     No 1. Has the patient ever had a metallic foreign body in the eye or ever been a grinder, metal worker or welder? If so, orbital X-rays are required.
 
  2. Does the patient have:
Yes     No • cardiac pacemaker, wires or defibrillator (ABSOLUTE CONTRAINDICATION)?
Yes     No • cerebral aneurysm clip (ABSOLUTE CONTRAINDICATION)?
Yes     No • ocular (eye) or cochlear (ear) implant (ABSOLUTE CONTRAINDICATION)?
Yes     No • artificial cardiac valve?
Yes     No • electrical stimulator for nerves and bones?
Yes     No • shrapnel/bullets?
Yes     No • metallic devices or objects in or on body (e.g., surgical clips, staples, metallic vascular stents, orthopedic hardware, other)?
 
Yes     No		  
3. Is the patient pregnant or nursing?
 
Yes     No 4. Has the patient had surgery in the area of interest?
 
Yes     No		  
5. Is the patient claustrophobic? If sedation (Ativan; to be supplied by referring physician), is required, the patient will be unable to drive following exam.
 
 
6. How much does the patient weigh? 
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