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English
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Request Appointment
Home
About Us
Our Services
MRI
MRA
Digital X-Ray
CAT Scan
DTI
Patients
Patient Registration Form
English
Spanish
Release of Information
English
Spanish
Insurance Plans
Accepted Forms of Payment
Appointment
Contact
Menu
Home
About Us
Our Services
MRI
MRA
Digital X-Ray
CAT Scan
DTI
Patients
Patient Registration Form
English
Spanish
Release of Information
English
Spanish
Insurance Plans
Accepted Forms of Payment
Appointment
Contact
Registration Form English
Patient Registration Form
Resolution Diagnostics MRI/Cat Scan Form
Name
(Required)
Sex
(Required)
Male
Female
DOB
(Required)
MM slash DD slash YYYY
Height: FT/INCH
(Required)
Weight:
(Required)
Describe your symptoms:
(Required)
Injury:
(Required)
Yes
No
Date of injury:
(Required)
MM slash DD slash YYYY
Surgery History:
(Required)
Female Patients
Pregnant:
(Required)
Yes
No
Unsure
Date of last menstrual Cycle:
(Required)
MM slash DD slash YYYY
Total or partial Hysterectomy:
(Required)
Yes
No
Allergy to MRI contrast:
(Required)
Yes
No
Allergy to CAT Scan contrast:
(Required)
Yes
No
Describe allergic reaction:
(Required)
MRI METAL SCREENING
Check all that apply:
(Required)
Pacemaker
Implanted Cardioverter Defibrilator
Aneurysm Coil Clip
Stents, Filters or Coils
Foreign body in orbits (eyes)
Neurostimulator and stim wires
Bone Fusion stimulator
Brain Shunt
IUD
Electrode patch
Cardiac loop recorder
Dentures\partial plate\retainer
Wig\Extensions
Medication patch
Heart valve
Tattoo Permanent makeup
Magnetic eye lashes
Joint replacement:
Magnetic Implant or any device
Cochlear or any ear Imp
Drug infusion pump
Brain DBS or VNS system
(Required)
I am of sound mind and I attest that everything I have filled out is to the best of my knowledge.
Signature
(Required)
Print Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
