2405 ATHERHOLT ROAD LYNCHBURG, VA 24501 MRI REQUEST SCHEDULING - (434) 485-8521 MRI APPOINTMENT DATE: ___/____/___ FAX(434) 485-8599 TIME: _________________ am pm PATIENT INFORMATION (PRINT) Patient’s Name _____________________________________________________________ Date of Birth _____ /_____ /_______ First M.I. Last Phone: (_______)______________________ Work: (_______)____________________ Cell: (_______)___________________ Diagnosis _________________________________________________________________________________________________ Insurance Carrier ________________________________________________ Referral/Authorization #: _____________________ (Attach Front & Back Copy of Insurance Card) Referring Physician ___________________________________________ Physician Office Contact _________________________ Phone (______) ______________________ Fax (______)__________________________ Patient’s Weight ______________ Creatinine ________________ (copy of lab results to be faxed for contrasted studies) TYPE OF MRI REQUESTED REFERRING PHYSICIAN REQUEST
Extremity ______________________________
Intelemage™
Go to https://share.intelemage.com and click “Signup now for a free account” to have
T-Spine results and images sent to you electronically.
L-Spine Contact us for more information at 434.485.8521.
_____________________________________________________________________________________ Physician’s Signature (Required) Date Health History Questionnaire for MRI WARNING! If you have impaired kidney function, require kidney dialysis, or have a personal history of kidney disease, please notify a staff member IMMEDIATELY.
Patient Name____________________________________________________ Date of Birth ___/___/___
Examination Type ___________________________________________ Examination Date ___/___/___
No Do you have any drug allergies? Please list:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
No Are you or could you possibly be pregnant?
No Are you breast-feeding? Breast milk should be discarded for 48 hours after injection.
No Have you ever had a previous allergic reaction to MRI contrast?
No Do you have severe allergies (not minor seasonal allergies)?
No Do you have a history of kidney disease? Kidney transplant?
No Do you have severe liver disease? Recent liver transplant or currently awaiting transplant?
No Do you have poorly controlled hypertension? (Greater than 180/110 mmHg)
No Do you have cardiomyopathy or congestive heart failure?
No Do you have diabetes? If yes please answer the following:
No Are you currently under the care of a physician for your diabetes?
No Do you have retinopathy? (eye disease related to your diabetes)
No Do you have neuropathy? (Numbness, tingling, burning in extremities)
No Do you have a history of stroke or TIA?
No Do you have any lower extremity problems? (cold feet or legs, infections, sores that won’t heal)
No Are you currently taking any medication containing metformin? These include Metformin (generic), Avandamet,
Glucophage, Glucophage XR, Glucovance, Metaglip, Glumetza, Fortamet, Riomet, ACTOPLUS Met, and Janumet.
I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form, and have had the opportunity to ask questions regarding the information on this form and the procedure I am about to undergo. Signature of Person Completing Form: ________________________________ Date _____/_____/_____ Signature of Technologist: __________________________________________ Date _____/_____/_____
17 - COUNTY CLERK RECORDING & FILING FUND $183.60 32 - BOLES ACRES FIRE DISTRICT $1,856.46 56 - SIXTEEN SPRINGS CANYON FIRE DISTRICT $41.54 65 - EMERGENCY MEDICAL SERVICES FUND $5,230.03 72 - ENVIRONMENTAL/CONVENIENT CENTER FUND(72) $6,434.71 ------------- TOTAL EXPENDED $158,276.87 The following claims now on file with the County Manager were examined, audited and approved for payment