Get the free Stand-Up MRI Patient Referral Form - Clermont Radiology

871 Oakley Server Drive, Clermont, Florida 34711 Phone: 352.241.6100 www.ClermontRadiology.com Stand-up MRI Patient Referral Form Appointment Date: Fax: Email: 352.241.6101 Info ClermontRadiology.com

How to fill out stand-up mri patient referral

How to fill out stand-up MRI patient referral:

1. Start by obtaining the referral form from the healthcare provider or the stand-up MRI facility. This form is necessary to initiate the process and ensure proper documentation.
2. Fill out the patient's personal information accurately, including their full name, date of birth, contact details, and any relevant medical identification numbers.
3. Provide the referring physician's information, such as their name, address, and contact number. This ensures seamless communication between the referring physician and the stand-up MRI facility.
4. Specify the reason for the referral. This could include symptoms experienced by the patient, suspected medical conditions, or any specific area of concern that requires assessment through the stand-up MRI procedure.
5. If the patient has any relevant medical history, such as previous injuries or surgeries, it is important to include this information as it may impact the assessment or interpretation of the MRI scan.
6. Indicate any medications that the patient is currently taking, including dosage and frequency. This helps the healthcare professionals to be aware of any potential interactions or contraindications before the MRI scan.
7. If the patient has any known allergies or adverse reactions to contrast agents or medications, make sure to include this information to prevent any complications during the procedure.
8. If an insurance claim is involved, provide the necessary insurance details, such as the policyholder's name, policy number, and contact information. It is essential to check whether stand-up MRI services are covered by the patient's insurance plan beforehand.
9. Before submitting the referral form, double-check all the information for accuracy and completeness to avoid any delays or issues during the scheduling of the stand-up MRI appointment.

Who needs stand-up MRI patient referral:

1. Individuals experiencing chronic or persistent back pain or neck pain that requires further investigation beyond a regular MRI.
2. Patients with symptoms or suspected conditions related to the spine, such as herniated discs, spinal stenosis, or spinal tumors.
3. Individuals who have difficulty lying flat or holding their breath during a traditional MRI scan, making the stand-up MRI a more suitable option.
4. Patients who require dynamic imaging, where their symptoms worsen or change with particular movements or positions, which can be better evaluated with a stand-up MRI.
5. Individuals who prefer or require an open MRI experience due to anxiety, claustrophobia, muscular bodybuild, or a larger body size. The stand-up MRI offers a more relaxed and comfortable experience for such patients.
6. Patients who seek a comprehensive evaluation of their spinal alignment and mobility, particularly in cases of scoliosis or posture-related concerns.

It is essential to consult with a healthcare professional or the stand-up MRI facility to determine the specific criteria for requiring a stand-up MRI patient referral in your specific location or healthcare system.

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