Transcription of MRI Request Form - Alberta Health Services
1 04998 (Rev2017-07)Previous Treatment oChemotherapy oRadiation Therapy oSteroidsIf yes, Where: When:MRI RequestSafety Screening: MRI Exams will notbe booked unless the following sections are review with the General AnesthesiaIs GA required? oNo oYesWeight okgolbsHeight ocmoinRenal Insufficiency oNo oYes On Dialysis oNo oYes run days: _____If no current results available, please indicate date ordered (yyyy-Mon-dd)Serum Creatinine (within 90 days)GFRDate(yyyy-Mon-dd)Screening ItemNoYesIf Yes: Cardiac pacemaker, defibrillator ooMake/Model: Year:Coronary artery stentsooMake/Model: Year:Metallic vascular clips (aneurysm clips)ooMake/Model: Year:Implanted Power Compatible CVCooMake/Model: Year:Metallic foreign body/implantsooSpecify.
2 Has the patient ever had a metal foreign body in the eyeoon/aAny previous surgeryooDate: Area: Date: Area: Hypertension or long standing insulin dependent diabetesooSpecify:ClaustrophobicooSedati on type oOral precautionsooSpecify:Pregnantoon/aMechan ical lift/transfer requiredooSpecify:<Fax to Diagnostic Imaging; fax numbers listed <Urgent/Emergent requests must bediscussed by direct consultation withthe radiologistPreferred FacilitySpecific anatomical area to be examinedRelevant clinical history/presumptive diagnosisClinical question to be answeredPatient label here or information below is requiredLast NameFirst NameBirthdate (yyyy-Mon-dd)Gender Address (street, city, province, postal code)PHND aytime PhoneInpatient locationWCB Claim NumberRelevant Previous Imaging StudiesLocationTypeDate(yyyy-Mon-dd)Atta ched copyoNo oYesReferring Physician(PRINT first and last name)Physician Phone(required)Physician Fax(required)
3 Contact Number for CriticalTest Results (required)SignatureDate (yyyy-Mon-dd)Copy to Physician (first and last)Copy to FaxDepartment Use OnlyPriority oOP1 oOP2 oOP3 oOP4, specify date:RadiologistProtocolEnhancedoNo oYesDate Received (yyyy-Mon-dd)Time Received (hh:mm)Appointment Date (yyyy-Mon-dd)Appointment time (hh:mm)
