Mri Request Form - Mount Sinai Hospital
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1Tel: 416-323-7515
Tel: 416-586-4941
Tel: 416-946-2026
MRI REQUEST
Fax: 416-323-6316
Fax: 416-586-4797
Fax: 416-946-2296
Patient Information
Medical Record No.: ___________________ Health Card No.:__________________________ Version Code: __________
Name:___________________ _________________________ DOB: _______/ _________/ __________
Sex:
M
F
First Name
Last Name
dd
mm
yyyy
Address: ________________________________________ City: _______________ Prov.: ______ Postal Code:________
Home Tel.: _________________________Cell: ____________________________ Business Tel.: ___________________
Additional Info.:
Walking
Mobility Status:
Wheelchair
Stretcher
Ambulance
______________________________________________________________
Non Resident/
Claim Number/Insurance No.: _____________________
Billing Information:
OHIP
WSIB
Other
(include attachments if necessary)
To be completed by Patient
FOR PATIENT SAFETY THESE QUESTIONS MUST BE ANSWERED:
Do you have any of the following?
Have you ever had surgery on your?
YES NO
(check all that apply)
(check all that apply)
Have you had a previous MRI?
Aneurysm Clips
Name all Surgeries:
Abdomen/
Has metal ever gone into your eye?
__________________
Artificial Cardiac Valve
Pelvis
Do you have any kidney disease?
__________________
Cardiac Pacemaker
Arms/
Are you on dialysis?
__________________
Cochlear Implants
Legs
Could you be pregnant?
Coils/Stents
Chest
Date of last Menstrual Period: ____________
Approximate year
Neurostimulator
of surgeries
What is your current Weight:______________
Head
Retained Pacing Wires
(add additional pages if
(maximum allowable weight 550lbs./250kg,
:
Shrapnel / Bullets
necessary)
Neck
but dependent on girth)
__________________
Other Implanted Devices: _________
Spine
What is your current Height:______________
__________________
(add additional pages if necessary)
Patient’s Signature: X _______________________________
Referring Physician Information
Exam Information
Area to be Scanned
(be specific):
Physician’s Name: ____________________________
Clinical Information /Working Diagnosis:
Address:____________________________________
_______________________Postal Code:__________
Phone: __________________ Fax: ______________
Completed Tests and Associated Results
Sites:
TGH
TWH
MSH
PMH
WCH
Outside Hospital/Clinic
(if from outside hospital, attach outside report)
Tests:_____________________________________________________________________________________________
Does the patient require an interpreter?
If yes, what language?____________________________________
No
Yes
IMPORTANT INSTRUCTIONS for Referring Physicians
If the patient has impaired renal function, you must submit a serum creatinine done within 3 months of the MRI appointment.
For many implanted devices it is absolutely critical TO LIST THE MANUFACTURER AND MODEL NUMBER to ensure that
the patient is not harmed in the magnet. For more information, see supplementary info sheet. Submit all surgical reports
available.
Physician’s Signature: X _________________________________
Date: ________________
INCOMPLETE/ILLEGIBLE REQUESTS WILL BE RETURNED/FAXED BACK WITHOUT AN APPOINTMENT
FORM MUST BE COMPLETE, INCLUDING PATIENT AND PHYSICIAN SIGNATURES
Form 2766 (Rev. 25/11/ 2011)
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