Please bring this order to your appointment on (date)_________________ at (time) _____________
EALTH RADIOLOGY SAINT MARY’S LOCATIONS SCHEDULE BY FAX WITH SCREENING QUESTIONS
Patient Name:______________________________________ Date of Birth:__________________ Pt. Phone:__________________
Procedure / Area to be examined:______________________________________________ PT Height________ Weight:__________
Clinical signs or symptoms:_______________________________________________________Authorization #:_________________
Physician name:_________________________ Physician Signature:___________________________________Date:_____________
MRI Screening Questions: Please check all that apply.
Have you had prior MRI or CT exams of the area being scanned?
Has there been prior surgery on the area to be scanned?
Is there any history of cancer?
Are you claustrophobic?
Have you EVER had an injury to your eyes caused by metal?
Do you have a pacemaker or ICD defibrillator? PATIENT:
Please register by calling 616.685.6094 or
Do you have any fragments of metal in your body?
online at www.SMpatientRegistration.com
& bring prior films not taken at SMHC.
Do you wear a hearing aid?
Do you wear dentures? Are they held in place by magnets?
Do you have any orthopedic devices (pins, wires, rods, plates,
screws, splints, back or leg braces) artificial limb or joint?
Have you had eye or ear implants?
Do you have an artificial cardiac valve, limb or joint?
Do you have a neuro or bio stimulator?
Do you have aneurysm clips?
Do you have a vena cava umbrella (blood clot filter)?
Do you have breast implants, tissue expander, or penile implant?
Are you using an intrauterine contraceptive device containingmetal?
Do you have a cervical halo or cervical collar?
Do you have an implanted insulin infusion pump or other implanted drug pump?
Could you possibly be pregnant?
I understand that yes answers may indicate the need for added procedures or exclude me from having an MRI for my EALTH RADIOLOGY SAINT MARY’S LOCATIONS SCHEDULE BY FAX WITH SCREENING QUESTIONS
_________________________ Date of Birth:__________________ Pt. Phone:__________________
Procedure / Area to be examined:______________________________________________ PT Height________ Weight:__________
Clinical signs or symptoms:_______________________________________________________Authorization #:_________________
Physician name:_________________________ Physician Signature:___________________________________Date:_____________
OFFICE FAX:_________________ PH: ____________ SCHEDULER:___________ ******************************************************************* WET READ REQUESTED CALL TO (Phone #): Appt Date: ________________ Time: ________am/ pm Location:__________________ Pt. called Appt. Mailed to Pt. ____________________ PATIENT: Please register by calling 616.685.6094 or online at & bring prior films not taken at SMHC. ARTHROGRAM COMPREHENSIVE INTERVENTIONAL ULTRASOUND GENERAL BREAST CENTER **Need H&P __________________ NUCLEAR MEDICINE CT Screening Questions:
BIOPSY **Need H&P Allergy to iodinated contrast? Yes or No
Paracentesis **Need H&P Is Pt. taking glucophage
Thoracentesis **Need H&P or glucovance? Yes or No Prev. films of area? Last Blood Creatinine =________ Date:________ DIAGNOSTIC X-RAY Known renal insufficiency? Yes or No FLUOROSCOPY ULTRASOUND OB
Other____________ ___________________
Myelogram **Need H&P
Other______________
MEDICINES INFORMATION HALOPERIDOL decanoate injection Pronounced: hal-o-per-ee-dol de-can-o-ate What is haloperidol injection used for? others need to stay on medication longer. Taking medication regularly may Haloperidol belongs to a group of medicines cal ed antipsychotics, prevent you from becoming unwel . Your doctor should regularly review which are usual y used to help
EALTH RADIOLOGY SAINT MARY’S LOCATIONS 
EALTH RADIOLOGY SAINT MARY’S LOCATIONS