Reminder: A physician must order your scan before the procedure can take place.

Prior to every MRI scan, we collect information from the patient to make sure it is safe to have the procedure. We collect patient demographic data and then review medical history. We will also collect insurance information and attempt to contact your insurance carrier to assist with determining benefits and pre-authorization whenever needed. We can now do some of this preliminary information gathering on-line. If you would like to shorten the length of the pre-registration phone call, you may complete the following patient demographic data and submit it to us along with a phone number at which we may call you to complete the pre-registration process.

The 2nd part of the process, in which we will review your medical history and insurance information, is just as critical to the pre-registration process and the initial information gathering so please be sure to contact us prior to your study if we have not been able to get in touch with you.

Patient Name:

*Has the patient ever had an MRI Scan done at NEW MRI Center
(any of our locations)?

yes no don't know

Sex:

M F

Date of Birth:

JanFebMarchAprilMayJuneJulyAugSeptOctNovDec 01020304050607080910111213141516171819202122232425262728293031 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987 1988 1989199019911992199319941995199619971998199920002001200220032004 2005

Home Phone:

- -

Address:

City:

State:

Select State: WI AL AK AZ AK CA CO CT D.C. DE FL GA HI ID IL ID IA KA KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WY

Zip:

Employer:

Employer Phone #:

- -

Emergency contact
(third party, other than your home phone #)

Name:

Relationship:

Phone Number:

- -

Area being scanned:

Reason for study:
(in your own words)

Ht:

feet inches

Weight:

lbs.

Person completing this form:

Name:

If other, please explain:

Do you have any specific questions you’d like to have addressed when
we contact you to complete the
pre-registration process?

We must now call you to collect information regarding your medical history and to give you instructions.
We can call between 7:30 a.m. and 6:00 p.m. Monday through Friday.
Best # to reach you at:

- -

Best time to call:
(between 7:30 a.m. - 6:00 p.m.)

Alternate # if we are unable to reach you at the above #:

- -

Best time to call:
(between 7:30 a.m. - 6:00 p.m.)