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Request for Radiologic Consultation
Please fill in Exam Request information here!
Patient
Appt Day and Time
Area to be Scanned:
Reason for Exam
EXAM REQUEST
MRI w/o contrast MRI w/conrast
NON-INVASIVE VASCULAR ASSESSMENT MRA
CT Scan X-Ray UPPER GI SERIES
IVP BARIUM SWALLOW

Transportation needed Yes No

Remarks Comments











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INSTRUCTIONS:
- 1 Where comfortable, loose clothing (e.g. a jogging suit) without metal zippers, snaps or trim and please leave valuables at home.

- 2 Please plan to arrive a minimum of 15 minutes before your appointment time and sign in at the reception desk.

- 3 You are welcome to bring a CD of your choice for your listening pleasure or music will be provided.

- 4 You CAN NOT have an MRI if you have a cardiac pacemaker, intra cranial aneurysm clip or metal fragments in your eyes or if you weight more than 550 pounds.

- 5 You may eat and drink as usual on the day of your exam. CT scan patients should call for special instructions.

- 6 Depending upon your insurance coverage a minimum deposit of $250.00 may be requested at the time of appointment.

- 7 If you think that you may be claustrophobic, please call us in advance for special instructions.

- 8 Please bring a completed insurance form (except for Medicare) and your Medicare or insurance card with you.

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