SYNERGY ADVANCED IMAGING - OnlineAgency



CENTRAL TEXAS IMAGING/CENTRAL TEXAS OPEN MRI

PATIENT NAME_____________________________________________________DOB____________ MALE___FEMALE___

MAILING ADDRESS__________________________________________________MARITAL STATUS S___M___W___

CITY__________________________STATE___________ZIP__________SS#___________________WEIGHT_____________

PHONE #____________________________________________ ALTERNATE #_______________________________________

EMERGENCY CONTACT_______________________________RELATIONSHIP_____________PH #__________________

PATIENT’S EMPLOYER____________________________ ADDRESS_____________________________________________

EMPLOYER’S PH#___________________________REFERRING PHYSICIAN_____________________________________

PRIMARY INSURANCE _______________________________SECONDARY INSURANCE___________________________

PRIMARY INSURED_______________________________DOB__________ADDRESS________________________________

_________________________________________________________________PHONE#_______________________

MEDICAL REVIEW

Y__N__Cardiac Pacemaker Y__N__Artificial Heart Valves Y__N__Drug Infusion Device

Y__N__Bullets/Schrapnel Y__N__Eye Implants Y__N__If female, are you pregnant?

Y__N__Ear Implants Y__N__IUD/Pessary/Diaphram Y__N__Date of last menstrual cycle

Y__N__Brain Aneurysm Clips Y__N__Claustrophobic Y__N__If female, are you breastfeeding?

Y__N__Shunt or Stent Y__N__Body Piercings Y__N__Have you had metal removed from your eyes

Y__N__Any type Prosthesis Y__N__Pacing Wires Y__N__Metal rods, pins, screws, etc.

Y__N__Hearing Aids Y__N__Dentures/Partials Y__N__History of Cancer

Y__N__Neurostimulators Y__N__Prior Brain Surgery Y__N__Kidney Problems/Dialysis

MEDICATIONS__________________________________DRUG ALLERGIES/FOOD________________________________

______________________________________________________PREV MRI, CT X-RAY ON SAME AREA___________________________

______________________________________________________WHERE WAS IT DONE ?________________________________________

______________________________________________________SURGERY ON SCANNED AREA ?________________________________

SYMPTOMS

Y__N__Injury/Trauma Y__N__Vision loss Y__N__Swelling

Y__N__Headaches Y__N__Upper Extremity pain, weakness, numbness Y__N__Redness/Soreness

Y__N__Seizures Y__N__Lower Extremity pain, weakness, numbness Y__N__Aching

Y__N__Hypertension Y__N__Neck pain Y__N__Limited Range of Motion

Y__N__Previous Stroke Y__N__Middle Back Pain Y__N__Mass

Y__N__Hearing Loss Y__N__Low Back Pain Y__N__Instability/Popping

Date symptoms started______________Briefly describe problem______________________________________________________________

_____________________________________________________________________________________________________________________

I attest that the information above is correct to the best of my knowledge. I give consent to the examination ordered by my physician.

According to the information above, I acknowledge that I have give this facility the right to file my insurance for payment of services

rendered and I agree to pay any balance remaining on the account after my insurance has denied payment . I understand I must pay

any coinsurance or deductible at time of service and I understand the quote for coinsurance and/or deductible is only an estimate.

This information may be may be given to the radiologist for payment of services rendered for the interpretation of the examinations.

I authorize release of my medical information to and from physicians, nursing facilities and/or other health care agencies to which I

may be referred to transferred. ***This is notification that certain services that are deemed necessary by your physician may not be

reimbursed by your insurance company, including Medicare. I also acknowledge receipt of Notice of Privacy Practices available in

this office PATIENTS OR GUARDIANS SIGNATURE_______________________________________________________DATE_______________

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