Extremity Mri Order Form
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1
2EXTREMITY MRI ORDER FORM
Tax ID 04-3627188
Contact us toll free:
NPI 1528058245
1-866-398-7364
1-866-267-0144
Call
or Fax
Excellence in Extremity MRI
Date _________________________
Patient’s Name ____________________________________________
Patient’s Phone 1 (______)______________________
Patient’s Phone 2 (______)______________________
Male
Insurance Name ____________________________________________
Female
Insurance ID# ______________________________________________
DOB _________________________
MRI ORDER FOR
LEFT
RIGHT
BOTH
Note SPECIFIC AREA OF INTEREST
_
_________________________
Forefoot
__________________________
Midfoot
__________________________
Hindfoot/Ankle
__________________________
Lower Leg
Knee
Hand
Wrist
Lower Arm
Elbow
Note CURRENT DIAGNOSIS or REASON FOR
Choose an EIP Center:
TREATMENT
Austintown, OH
Fairlawn, OH
_
_________________________
Beachwood, OH
Dayton, OH
__________________________
Middleburg Hts, OH
Ontario, OH
Canton, OH
Worthington, OH
__________________________
__________________________
Precert # ____________________________________
Referring Dr. (print name) _____________________________________________________________
Phone (_______) ___________________________ Fax (_______) ___________________________
Dr. SIGNATURE ____________________________________________________________________
Thank you for choosing EIP!
Check any that apply:
Pacemaker/Defibrillator
Worked w/ metal, hit in face/eyes w/ metal, metal
removed from face/eyes (need orbital x-rays)
Recent surgery in area of interest ( fax op report)
Implanted device (ex, cochlear implants, bone
stimulators, pins/screws, etc.)
Heart valve/stent (need card or op report)
Brain surgery/aneurysm clips
Possibility of Pregnancy
Weighs >350lbs
Previous MRI (any kind)
Was seen at EIP before
Appointment Date _____________________
NONE APPLY
Appointment Time _____________________
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