Medical Imaging Request Form (MRI / Ultrasound / X-Ray)
Please complete this form for all MRI requests
Today's Date
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Month
-
Day
Year
Date
Legal Name
*
First Name
Last Name
Preferred name (optional):
Date of birth
*
/
Month
/
Day
Year
Date
Now
*
-
Month
-
Day
Year
Date
Age (calculated, office use)
BC Care Card / Personal Health Number (for labs, results, prescriptions, etc)
*
What is your weight? (indicate Kg or lbs)
What is your height? (cm or in)
Your email:
*
example@example.com
Your Tel No:
*
Which type of imaging are your interested in?
As recommended by doctor
MRI
Ultrasound
X-Ray
Other
Which body area are you interested in checking? (please check all that apply)
As recommended by doctor
Shoulder(s)
Elbow(s)
Hand(s)
Hip(s)
Knee(s)
Neck
Upper Back
Lower Back
Other
Which side?
As recommended by doctor
Left
Right
Bilateral (both sides)
Do you have a preference for a particular medical imaging lab?
As recommended by doctor
Priority MRI
Elysium MRI
West Coast Imaging (ultrasound)
Downtown Radiology and Ultrasound (sports med)
Other
Patient Screening (for MRI). Do you have any history of:
Rows
Yes
No
Cardiac Pacemaker or Defibrillator
Cerebral Aneurysm Clip
Internal electrodes or wires
Eye or ear implant
Metallic foreign body in eye
Shrapnel or bullet fragment
Intravscular coil, stent or filter
Breast tissue expander
Infusion pump or stimulator
Are you pregnant?
Are you breastfeeding?
Are you claustrophobic?
Please indicate the reason for the imaging request:
Please list any allergies or sensitivities here:
Any previous relevant exams? Please indicate when and where:
Certification
I certify that I have answered all questions to truthfully to the best of my knowledge and will advise my treatment provider if there are any changes to my health history in the future.
Name Printed
*
Patient Signature
*
Continue
Continue
Should be Empty: