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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