MRI Scheduling MRI Scheduling In order to process the appointment, please complete all of the information below. A coordinator will schedule an appointment as quickly as possible. Please ensure the accuracy of the information provided.Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Primary Phone(Required)Secondary PhoneRequesting Physician/Provider(Required) Physician Full Name Clinic Contact Name(Required) Physician/Clinic Phone(Required)Authorization Number(Required) Insurance(Required) Insurance Policy Number(Required) Is the patient over 60 years old?(Required) Yes No Is the patient claustrophobic?(Required) Yes No Speak with the patient's physician about approval for pre-medication before this procedure, or ask them about scheduling the MRI at the Watson Chapel Health Complex. The MRI Machine at the facility has a larger opening.Does the patient currently have a pacemaker or defibrillator?(Required) Yes No DO NOT SCHEDULE BEFORE CONTACTING MRI STAFF. THEY WILL CONTACT THE MANUFACTURER TO ENSURE THE DEVICE IS MRI SAFE. PLEASE CALL 870-541-6497Does the patient currently have an Interstem Bladder Stimulator?(Required) Yes No DO NOT SCHEDULE THIS PROCEDURE, PLEASE CONTACT THE PHYSICIAN.Has the patient ever had brain surgery?(Required) Yes No DO NOT SCHEDULE BEFORE CONTACTING MRI STAFF. NOTIFY THEM OF ANY ANEURYSM CLIPS THAT THE PATIENT MAY HAVE. THEY WILL CONTACT THE MANUFACTURER TO ENSURE THEY ARE MRI SAFE. PLEASE CALL 870-541-6497Has the patient had any recent cardiac or other shunt/stint placements in the last 8 weeks?(Required) Yes No It is unsafe to schedule this procedure within 8 weeks of any shunt/stint placement. Please wait to schedule this procedure until AT LEAST 8 weeks have passed since this placement.Does the patient have any metal fragments in their body?(Required) Yes No (bullets, shrapnel, etc.)Does the patient have a drug infusion pump, such as those for Insulin or Chemo?(Required) Yes No The pump must be removable, as it cannot be on the patient for this procedure.Has the patient ever had lower back surgery? (Not including steroid or cement injections)(Required) Yes No Has the patient previously had an MRI?(Required) Yes No What was the location of the previous MRI?(Required) Name of medical facility, City/State, etc.)Disclaimer Any device such as heart monitor, glucose or medication monitor/dispenser should be removed prior to MRI. Height (Ft/In)(Required) Example: 6'2", 6 Feet 2 Inches, 6 Ft 2 InWeight in Pounds (lbs)(Required)Procedure(Required)MRA ABD & BLEMRA Abd WWO ConMRA Chest WWO ConMRA Head WO ConMRA Lower Ext WWO ConMRA Neck W ConMRA Neck WO ConMRA Neck WWO ConMRA Pelvis WWO ConMRCP MRI AbdMRI Abd With ContrastMRI Abd WO ConMRI Abd WWO ConMRI Brain W ConMRI Brain WO ConMRI Brain WWO ConMRI Chest W ConMRI Chest WO ContrastMRI Chest WWO ConMRI CSpine W ConMRI CSpine WO ConMRI CSpine WWO ConMRI IACS W ConMRI Lower Ext Joint W Con (Right/Left/Bilateral)MRI Lower Ext Joint WO Con (Right/Left/Bilateral)MRI Lower Ext Joint WWO Con (Right/Left/Bilateral)MRI Lower Ext W Con (Right/Left/Bilateral)MRI Lower Ext WO Con (Right/Left/Bilateral)MRI Lower Ext WWO Con (Right/Left/Bilateral)MRI LSpine W ConMRI LSpine WO ConMRI LSpine WWO ConMRI Orbits W ConMRI Orbits WO ConMRI Orbits WWO ConMRI Pelvis W ConMRI Pelvis WO ConMRI Pelvis WWO ConMRI Soft Tissue Neck W Con (Right/Left/Bilateral)MRI Soft Tissue Neck WO Con (Right/Left/Bilateral)MRI Soft Tissue Neck WWO Con (Right/Left/Bilateral)MRI TMJSMRI TSpine W ConMRI TSpine WO ConMRI TSpine WWO ConMRI Upper Ext Joint W ConMRI Upper Ext Joint WO Con (Right/Left/Bilateral)MRI Upper Ext Joint WWO ConMRI Upper Ext W ConMRI Upper Ext WO Con (Right/Left/Bilateral)MRI Upper Ext WWO ConMYELO2VWSDiagnosis Code(Required) Appropriate Use Criteria G Code Please contact MRI prior to scheduling this procedure.Additional Procedure (If Applicable)No Additional ProcedureMRA ABD & BLEMRA Abd WWO ConMRA Chest WWO ConMRA Head WO ConMRA Lower Ext WWO ConMRA Neck W ConMRA Neck WO ConMRA Neck WWO ConMRA Pelvis WWO ConMRCP MRI AbdMRI Abd With ContrastMRI Abd WO ConMRI Abd WWO ConMRI Brain W ConMRI Brain WO ConMRI Brain WWO ConMRI Chest W ConMRI Chest WO ContrastMRI Chest WWO ConMRI CSpine W ConMRI CSpine WO ConMRI CSpine WWO ConMRI IACS W ConMRI Lower Ext Joint W Con (Right/Left/Bilateral)MRI Lower Ext Joint WO Con (Right/Left/Bilateral)MRI Lower Ext Joint WWO Con (Right/Left/Bilateral)MRI Lower Ext W Con (Right/Left/Bilateral)MRI Lower Ext WO Con (Right/Left/Bilateral)MRI Lower Ext WWO Con (Right/Left/Bilateral)MRI LSpine W ConMRI LSpine WO ConMRI LSpine WWO ConMRI Orbits W ConMRI Orbits WO ConMRI Orbits WWO ConMRI Pelvis W ConMRI Pelvis WO ConMRI Pelvis WWO ConMRI Soft Tissue Neck W Con (Right/Left/Bilateral)MRI Soft Tissue Neck WO Con (Right/Left/Bilateral)MRI Soft Tissue Neck WWO Con (Right/Left/Bilateral)MRI TMJSMRI TSpine W ConMRI TSpine WO ConMRI TSpine WWO ConMRI Upper Ext Joint W ConMRI Upper Ext Joint WO Con (Right/Left/Bilateral)MRI Upper Ext Joint WWO ConMRI Upper Ext W ConMRI Upper Ext WO Con (Right/Left/Bilateral)MRI Upper Ext WWO ConMYELO2VWSDiagnosis Code(Required) Appropriate Use Criteria G Code Please contact MRI prior to scheduling this procedure.Additional Procedure 2 (If Applicable)No Additional ProcedureMRA ABD & BLEMRA Abd WWO ConMRA Chest WWO ConMRA Head WO ConMRA Lower Ext WWO ConMRA Neck W ConMRA Neck WO ConMRA Neck WWO ConMRA Pelvis WWO ConMRCP MRI AbdMRI Abd With ContrastMRI Abd WO ConMRI Abd WWO ConMRI Brain W ConMRI Brain WO ConMRI Brain WWO ConMRI Chest W ConMRI Chest WO ContrastMRI Chest WWO ConMRI CSpine W ConMRI CSpine WO ConMRI CSpine WWO ConMRI IACS W ConMRI Lower Ext Joint W Con (Right/Left/Bilateral)MRI Lower Ext Joint WO Con (Right/Left/Bilateral)MRI Lower Ext Joint WWO Con (Right/Left/Bilateral)MRI Lower Ext W Con (Right/Left/Bilateral)MRI Lower Ext WO Con (Right/Left/Bilateral)MRI Lower Ext WWO Con (Right/Left/Bilateral)MRI LSpine W ConMRI LSpine WO ConMRI LSpine WWO ConMRI Orbits W ConMRI Orbits WO ConMRI Orbits WWO ConMRI Pelvis W ConMRI Pelvis WO ConMRI Pelvis WWO ConMRI Soft Tissue Neck W Con (Right/Left/Bilateral)MRI Soft Tissue Neck WO Con (Right/Left/Bilateral)MRI Soft Tissue Neck WWO Con (Right/Left/Bilateral)MRI TMJSMRI TSpine W ConMRI TSpine WO ConMRI TSpine WWO ConMRI Upper Ext Joint W ConMRI Upper Ext Joint WO Con (Right/Left/Bilateral)MRI Upper Ext Joint WWO ConMRI Upper Ext W ConMRI Upper Ext WO Con (Right/Left/Bilateral)MRI Upper Ext WWO ConMYELO2VWSDiagnosis Code(Required) Appropriate Use Criteria G Code Please contact MRI prior to scheduling this procedure.Additional Procedure 3 (If Applicable)No Additional ProcedureMRA ABD & BLEMRA Abd WWO ConMRA Chest WWO ConMRA Head WO ConMRA Lower Ext WWO ConMRA Neck W ConMRA Neck WO ConMRA Neck WWO ConMRA Pelvis WWO ConMRCP MRI AbdMRI Abd With ContrastMRI Abd WO ConMRI Abd WWO ConMRI Brain W ConMRI Brain WO ConMRI Brain WWO ConMRI Breast Bilat W ConMRI Breast Unilat W Con (Right/Left)MRI Chest W ConMRI Chest WO ContrastMRI Chest WWO ConMRI CSpine W ConMRI CSpine WO ConMRI CSpine WWO ConMRI IACS W ConMRI Lower Ext Joint W Con (Right/Left/Bilateral)MRI Lower Ext Joint WO Con (Right/Left/Bilateral)MRI Lower Ext Joint WWO Con (Right/Left/Bilateral)MRI Lower Ext W Con (Right/Left/Bilateral)MRI Lower Ext WO Con (Right/Left/Bilateral)MRI Lower Ext WWO Con (Right/Left/Bilateral)MRI LSpine W ConMRI LSpine WO ConMRI LSpine WWO ConMRI Orbits W ConMRI Orbits WO ConMRI Orbits WWO ConMRI Pelvis W ConMRI Pelvis WO ConMRI Pelvis WWO ConMRI Soft Tissue Neck W Con (Right/Left/Bilateral)MRI Soft Tissue Neck WO Con (Right/Left/Bilateral)MRI Soft Tissue Neck WWO Con (Right/Left/Bilateral)MRI TMJSMRI TSpine W ConMRI TSpine WO ConMRI TSpine WWO ConMRI Upper Ext Joint W ConMRI Upper Ext Joint WO Con (Right/Left/Bilateral)MRI Upper Ext Joint WWO ConMRI Upper Ext W ConMRI Upper Ext WO Con (Right/Left/Bilateral)MRI Upper Ext WWO ConMYELO2VWSDiagnosis Code(Required) Appropriate Use Criteria G Code Please contact MRI prior to scheduling this procedure.Additional Procedure 4 (If Applicable)No Additional ProcedureMRA ABD & BLEMRA Abd WWO ConMRA Chest WWO ConMRA Head WO ConMRA Lower Ext WWO ConMRA Neck W ConMRA Neck WO ConMRA Neck WWO ConMRA Pelvis WWO ConMRCP MRI AbdMRI Abd With ContrastMRI Abd WO ConMRI Abd WWO ConMRI Brain W ConMRI Brain WO ConMRI Brain WWO ConMRI Chest W ConMRI Chest WO ContrastMRI Chest WWO ConMRI CSpine W ConMRI CSpine WO ConMRI CSpine WWO ConMRI IACS W ConMRI Lower Ext Joint W Con (Right/Left/Bilateral)MRI Lower Ext Joint WO Con (Right/Left/Bilateral)MRI Lower Ext Joint WWO Con (Right/Left/Bilateral)MRI Lower Ext W Con (Right/Left/Bilateral)MRI Lower Ext WO Con (Right/Left/Bilateral)MRI Lower Ext WWO Con (Right/Left/Bilateral)MRI LSpine W ConMRI LSpine WO ConMRI LSpine WWO ConMRI Orbits W ConMRI Orbits WO ConMRI Orbits WWO ConMRI Pelvis W ConMRI Pelvis WO ConMRI Pelvis WWO ConMRI Soft Tissue Neck W Con (Right/Left/Bilateral)MRI Soft Tissue Neck WO Con (Right/Left/Bilateral)MRI Soft Tissue Neck WWO Con (Right/Left/Bilateral)MRI TMJSMRI TSpine W ConMRI TSpine WO ConMRI TSpine WWO ConMRI Upper Ext Joint W ConMRI Upper Ext Joint WO Con (Right/Left/Bilateral)MRI Upper Ext Joint WWO ConMRI Upper Ext W ConMRI Upper Ext WO Con (Right/Left/Bilateral)MRI Upper Ext WWO ConMYELO2VWSDiagnosis Code(Required) Appropriate Use Criteria G Code Please contact MRI prior to scheduling this procedure.CommentsThis field is for validation purposes and should be left unchanged.