Transcription of MAGNETIC RESONANCE (MR) PROCEDURE …
{{id}} {{{paragraph}}}
Example: air traffic controller
MAGNETIC RESONANCE (MR) PROCEDURE …
Date _____/_____/_____ Patient Number _____ Name _____ Age _____ Height _____ Weight _____ Last name First name Middle Initial Date of Birth _____/_____/_____ Male Female Body Part to be Examined _____ month day year Address _____ Telephone (home) (_____) _____-_____ City _____ Telephone (work) (_____) _____-_____ State _____ Zip Code _____ Reason for MRI and/or Symptoms _____ Referring Physician _____ Telephone (_____) _____-_____ 1. Have you had prior surgery or an operation ( , arthroscopy, endoscopy, etc.)
Please indicate if you have any of the following: Yes No Aneurysm clip(s) Yes No Cardiac pacemaker Yes No Implanted cardioverter defibrillator (ICD)
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: