Get the free MRI Exam Order Form - Cheyenne Radiology Group

MRI EXAM ORDER FORM Date: / / Appointment Date & Time: / / : AM PM Patient Name: Date of Birth: / / Study Requested: Symptoms / History: Physician Signature: Printed: Routine: Phone Report: Please

How to fill out mri exam order form

How to fill out an MRI exam order form:

1. Gather patient information: Start by filling out the patient's full name, date of birth, contact information, and any other relevant details requested on the form. Ensure accuracy to prevent any confusion or delays in scheduling the MRI.
2. Provide demographics: The form may ask for demographic information such as gender, ethnicity, or social security number. Fill in the required fields accurately and securely following any privacy regulations.
3. Specify referring physician: Indicate the name and contact information of the referring physician who has ordered the MRI exam. This information helps to establish a connection and facilitate communication between the healthcare providers.
4. Include reason for the MRI: Clearly state the medical reason or condition that necessitates the MRI exam. The form may provide checkboxes or space for you to elaborate on the symptoms, diagnosis, or suspected condition. Be thorough and precise to ensure the correct scan is performed.
5. Provide relevant medical history: The form may have a section for the patient's medical history or previous imaging studies. Fill out this section accurately, mentioning any relevant details or prior scans that help provide context for the current MRI examination.
6. Mention any allergies or contraindications: If the patient has any known allergies or contraindications for certain medications or contrast agents used in MRI scans, make sure to communicate this information in the designated section. This helps the radiology department take necessary precautions during the procedure.

Who needs an MRI exam order form?

1. Patients referred for MRI: Any individual, regardless of age, who has been recommended by a healthcare professional to undergo an MRI scan will require an MRI exam order form. This form serves as a means of communication between the referring physician and the radiology department.
2. Radiologists and imaging centers: MRI exam order forms are essential for radiologists and imaging centers to receive accurate patient details, medical history, and the reason for the MRI. These forms ensure that the correct scan is performed, and that all necessary precautions and preparations are taken to ensure patient safety and comfort.
3. Insurance companies and records: MRI exam order forms are often used by insurance companies to validate and process claims. Additionally, these forms become part of the patient's medical records, allowing for easy reference to the ordered examination and its purpose in the future.

Note: It is essential to consult the specific guidelines and requirements of the institution where the MRI exam order form will be submitted, as the structure and content may vary. Always ensure that the form is filled out accurately and completely to facilitate a smooth and efficient MRI examination process.

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