Mri Procedure Referral Form - State Of Indiana
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1Patient Name:_____________________________________________ DOB:________________________________
SS#:____________________ Pt. Home Phone #:____________________ Pt. Work Phone #:__________________
Weight:________________
Sex:
□ Male
□ Female
Referring Physician:_______________________________________ Physician’s Office Phone#:_________________
Insurance Company:__________________________________________ Phone #:____________________________
Precert Required?: □ Yes
□ No Precert #:______________________
Work Comp?
□ Yes
□ No
Diagnosis:_______________________ Symptoms/Clinical Indications:______________________________________
______________________________________________________________________________________________
Previous Study?: □ Yes
□ No
Date:____________________ Facility:_____________________________
Previous Spine Surgery?: Level_______ Date_____________ History of Cancer?:___________________________
Other surgeries?:________________________________________________________________________________
SAFETY CONCERNS
Pacemaker/Aneurysm Clips/Biomedical Implants? □ Yes □ No Specify_______________________________
Injury to eyes with metal? □ Yes □ No If yes, has patient had an MRI since injury? □ Yes □ No Date_______
****If yes to injury with metal and no to MRI since injury, patient must have pre-MRI orbit x-rays
TYPE OF SCAN(S) ORDERED
□ Brain
□ Neck (Soft Tissue)
□ MRA Brain
□ Face/Neck/Orbits
□ Chest
□ MRA Neck
□ Cervical Spine
□ Abdomen
□ MRA Chest
□ Thoracic Spine
□ Upper Extremity L R Bilateral
□ MRA Abdomen
□ Lumbar Spine
○ Shoulder ○Elbow ○Wrist ○Hand
□ MRA Pelvis
○weight bearing/ axial loading □ Lower Extremity L R
Bilateral
□ MRA Lower Extremity
□ Pelvis
○Hip
○Knee
○Ankle
□ Arthrogram
□ Sacral Spine/SIJ
○Foot ○Thigh
○Lower Leg
□ Other__________________
□ Soft Tissue
□ Bony Structure
Contrast? (Circle one): Without With & Without
Sedation? (Circle one):
Yes
No
SPECIAL INSTRUCTIONS
Call patient to schedule (Circle one)
Yes
No
Report Status (Circle one)
STAT
ASAP
Routine
Desired Contact # (circle one and provide number) *Office *Cell *Pager #_____________________________
Allergies:___________________________________________________________________________________
_________________________________________
Date:_______________________
Physician Signature Required
THANK YOU FOR YOUR REFERRAL!
Please fax to: (317) 706-3417
Meridian MRI
8805 N. Meridian St. Indianapolis, IN 46260
Phone (317) 706-SCAN
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Parent category: Medical