McBride Clinic, Inc
Acct #:
Patient Name: DOB: Weight:
Allergies:
( ) Orbital Screening Study Ordered ( ) Electronic Implant – MRI Staff Contacted
( ) Orbits
( ) Sedation required ( ) Creatinine Ordered ( ) Previous Back Surgery
If the patient has a Defibrillator, Cardiac Pacemaker or Dorsal Column Nerve Stimulator you may NOT schedule an MRI.
If the patient has or has ever had a Cardiac Pacemaker removed you may NOT schedule an MRI.
If the patient has a Cerebral Aneurysm Clip, please contact the MRI staff prior to proceeding.
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( ) MRI ( ) MRA
( ) With Contrast ( ) Without Contrast ( ) With & Without Contrast
Procedure (if indicated) Intra-articular Joint Injection under Fluoroscopy
Medication/Dosage:
Diagnosis: ICD-10
Special Instructions:
DATE OF EXAM:
Arrival Time: Scan Time:
Ordering Physician: Date:
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PATIENT INSTRUCTIONS
( ) If you are having an Intra-articular Joint Injection, receiving contrast as a part of your MRI, having an MR Arthrogram or if you are claustrophobic, you will need someone to drive you home.
( ) If you are having a Lumbar Spine MRI, do not eat or drink anything three (3) hours prior to your procedure.
( ) If you are having an arthrogram, do not eat or drink anything four (4) hours prior to your procedure.
( ) If you have ever worked with metal or had metal in your eye you will need x-ray screening (orbits) prior to the procedure.
( ) Return Appointment Date Time Location
( ) The patient has been given a copy of the MRI Disclosure Statement
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