611 MRI Patient Pre-Registration Form

1

All questions with an * must be answered or marked N/A before you can move forward.

2

ALL Copays are to be paid in full at the time of the study. If you are not aware of this amount, there is a phone number on the back of your insurance card to call. When they ask what procedure you are having, we are designated as Advanced Imaging. Your insurance company should be able to give you the amount of the co-pay for your policy. Thank you.

3

COVID-19 MESSAGE

If you have been exposed to someone with COVID-19 or have any symptoms of COVID-19 (cough, fever, chills, loss of taste and smell, etc.), please call our office at 814-946-8000 before you pre-register. Thank you.

4

Name* This field is required.Please enter your first and last name.

First Name

Last Name

5

Birth Date* This field is required.Please enter your birth date.

6

Address* This field is required.Please enter your address information.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Email* This field is required.Please provide us with an email address.

example@example.com

8

Phone Number* This field is required.Please provide us with the best number for us to contact you at.

9

Height* This field is required.

10

Weight* This field is required.

11

Are you able to walk without assistance?* This field is required.

YESNO

12

Will you need a wheelchair, lifting assistance, etc.?* This field is required.

YESNO

13

Gender* This field is required.

Male

Female

Other

14

Are you currently pregnant?* This field is required.

YES

NO

NOT SURE

15

Are you currently breastfeeding?* This field is required.

YESNO

16

Please explain why you are having this exam, and give full details of your signs and symptoms. * This field is required.Please give full details of your symtoms

17

Have you had any X-rays, CTs, or MRIs of the body part being scanned at any facility other than 611 MRI?* This field is required.

YESNO

18

What type of imaging service did you receive on the body part 611 MRI will be scanning (MRI, X-Ray, CT, Ultrasound). Provide name of facility, location, and approximate date.* This field is required.Imaging Service Examples: MRI/MRA Scan, CT/CAT Scan, X-Ray, Ultrasound, Other, etc.

19

If the body part being scanned at 611 MRI has been scanned previously by any facility other than 611 MRI, we ask that you please bring your images on a CD and the report to your upcoming appointment at 611 MRI.

20

Are you Diabetic?* This field is required.If you wear a diabetic pump, it must be removed before the MRI Or if you wear a pod/patch on your arm, it must be removed

YES

NO

NOT APPLICABLE

21

Have you had a recent Iron Infusion?

YESNO

22

Are you taking any blood thinners?* This field is required.

YESNO

23

Please provide the name of the prescription.* This field is required.

24

If you have had any Blood Work done in the last 4 -6 weeks, please note below when and at what location was it drawn?

25

When is your follow up appointment with the doctor who ordered this study?Follow up

26

What type of imaging service are you scheduled for?* This field is required.

MRI/MRA

CT/CAT

27

Have you ever experienced problems related to a previous MRI procedure?* This field is required.If you've never had an MRI before, please select "NOT APPLICABLE."

YES

NO

NOT APPLICABLE

28

Please explain.* This field is required.

29

Have you ever been injured by a metallic object or foreign body?* This field is required.For example, a BB, bullet, shrapnel, etc.

YESNO

30

Have you ever had an injury to the eye involving a metallic object or fragment?* This field is required.

YESNO

31

Please explain.* This field is required.Someone from our office will contact you for further information.

32

Have you ever had brain surgery, brain aneurysm surgery, or a shunt placement?* This field is required.

YESNO

33

Please explain.* This field is required.Someone from our office will contact you for further information.

34

Have you ever had eye or inner ear surgery?* This field is required.

YESNO

35

Please explain.* This field is required.Someone from our office will contact you for further information.

36

Have you ever had heart surgery, or do you have a heart valve prosthesis or pacemaker?* This field is required.

YESNO

37

Please explain.* This field is required.Someone from our office will contact you for further information.

38

Do you have any mechanical devices such as a defibrillator, neurostimulator, bone stimulator, insulin pump, pain pump, tens unit, interstim device, hearing aids, or other?* This field is required.

YESNO

39

Please explain.* This field is required.Someone from our office will contact you for further information.

40

Have you had surgery for an abdominal aortic aneurysm, where a stent, IVC filter, or graft was placed?* This field is required.

YESNO

41

Please explain.* This field is required.Someone from our office will contact you for further information.

42

Have you ever had any stents implanted anywhere in your body?* This field is required.

YESNO

43

Please explain.* This field is required.Someone from our office will contact you for further information.

44

Do you have any kind of prosthesis, such as eye, leg, or arm prosthesis, penile implant, breast markers, clips, expanders, or any other implants?* This field is required.

YESNO

45

Please explain.* This field is required.Someone from our office will contact you for further information.

46

Please list all other surgeries you have had, where you had the surgery, and if you received an implant, what type? If no surgeries, type "None" in the box.* This field is required.Implant Examples: Graft, filter, stent, clips, staples, mesh, plate, expanders, prosthesis, etc.

47

Have you had a clip placed during a colonoscopy or endoscopy?* This field is required.

YESNO

48

Where did you have the procedure?* This field is required.

49

Have you ever swallowed a PillCam or had a Bravo capsule placement?* This field is required.

YESNO

50

Where did you have the procedure?* This field is required.

51

Do you have a medicine patch, tattoos, permanent makeup, pierced earrings, or body piercings?* This field is required.

YESNO

52

Please remove all body piercings and medicine patches prior to your exam.

53

Do you have uncontrolled blood pressure, kidney or liver disease, kidney or liver failure, or been on dialysis?* This field is required.

YESNO

54

Please explain.* This field is required.Someone from our office will contact you for further information.

55

Do you have any allergies to MRI contrast or gadolinium, Iodine, seafood or shellfish?* This field is required.

YES

NO

NOT SURE

56

Please explain.* This field is required.Someone from our office will contact you for further information.

57

Have you ever been diagnosed with cancer?* This field is required.

YESNO

58

What type of cancer?* This field is required.

59

Have you received chemo or radiation treatments?* This field is required.

YESNO

60

If currently under treatment, please provide the name(s) of medication(s).* This field is required.

61

Do you have any allergies to CT IV contrast, iodine, seafood, or shellfish OR any other medication?* This field is required.

YES

NO

I DON'T KNOW

62

Please explain.* This field is required.Someone from our office will contact you for further information.

63

Do you take any oral medication for diabetes or other medical conditions?* This field is required.

YESNO

64

Please explain.* This field is required.Someone from our office will contact you for further information.

65

Do you have a history of asthma?

YESNO

66

Have you ever been diagnosed with Multiple Myeloma?* This field is required.

YESNO

67

Have you ever been diagnosed with cancer?* This field is required.

YESNO

68

What type of cancer?* This field is required.

69

Have you received chemo or radiation treatments?* This field is required.

YESNO

70

If currently under treatment, please provide the name(s) of medication(s).* This field is required.

71

Do you have a history of kidney disease or surgery?* This field is required.

YESNO

72

Do you have any heart conditions?* This field is required.

YESNO

73

Please explain* This field is required.Someone from our office will be in touch.

74

Do you have high blood pressure?* This field is required.

YESNO

75

Do you have Rheumatoid Arthritis?* This field is required.

YESNO

76

Are you taking Methotrexate for arthritis or as a chemotherapy treatment?* This field is required.

YESNO

77

Do you have any implanted electronic devices such as a pacemaker, defibrillator, neurostimulator, bone stimulator, insulin pump, other pumps, or any other electronic devices?* This field is required.

YESNO

78

Please list all other surgeries you have had, where you had the surgery, and if you received an implant, what type? If no surgeries, type "None" in the box.* This field is required.Implant Examples: Graft, filter, stent, clips, staples, mesh, plate, expanders, prosthesis, etc.

79

If contrast was ordered for your CT, please call 814-946-8000 to make arrangements to pick up Barium and to review dietary instructions at least one day prior to your CT.

80

You are required to wear a facemask or face shield that covers your nose and mouth when you enter the 611 MRI building.

Be sure to bring a photo ID, Insurance Card, and Credit Card to be put on file.

We have reserved a time slot exclusively for you on very expensive equipment. There is also a technologist that has been assigned to your case, therefore it is very important that you arrive to your appointment on time.

We require 24 hour notice to reschedule or cancel an appointment. No shows will be required to pay a $100 non-refundable fee for the missed appointment. The $100 fee must be paid before we can reschedule an appointment.

As other facilities, we require Self Pay payments to be made in full at the time of the study.