Prostate MRI Appointment Booking

Patient Info

First

Last

Middle Initial

Date of Birth

Phone Number

Social Security #

Patient Email *

Confirm Email

Street Address *

City *

State *

Zip Code *

Referring Physician

First

Last

Physician Phone Number

Physician Address

Physician City

Physician State

Physician Zip/Postal Code

Insurance Info

Insurance Company

Date of Injury

Claim/ID #

Group/Policy #

Insurance Contact

Employer at Time of Injury

Employer Contact

Attorney Info

First

Last

Attorney Phone Number

Attorney Address

Attorney City

Attorney State

Attorney Zip/Postal Code

Do you have a pacemaker or any implanted wires? *

Have you had Cerebral Aneurism Surgery? Any clips? *

Do you have an implanted neurostimulator system? *

Do you have any implanted mechanical pumps? *

Do you have any magnetic dentures or other prosthesis? *

Do you have any stents, coils, filters, or shrapnel in your body? *

Have you ever had brain surgery? *

Have you ever had a metallic foreign body in your eyes removed? *

Have you ever worked with metal/worked as a welder? *

Have you ever had any inner ear surgery or ear implants? *

Have you ever had any cochlea implants? *

Have you ever had Abdominal Aortic Aneurism Surgery? *

Have you ever had cancer? Do you wear any medical patches? *

Have you ever had any other type of surgery? *

If yes, when and what type of surgery? *

Have you ever had an MRI? *

If yes, when and where?

I ATTEST THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I HAVE READ AND UNDERSTAND THE CONTENTS OF THIS FORM AND HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THE MRI PROCEDURE THAT I AM ABOUT TO UNDERGO *

I AGREE

Name

Voyageur imaging, llc

393 North Dunlap Street
Suite LL40
St Paul, MN 55104

Appointment booking

Tel: 651-647-0000

Fax: 651-647-1111

*Operadores de habla española disponibles.