QJASTAL VALLEY

MEDICAL IMAGING EXPERTS

TAX ID #941723382

626 Brunken Avenue, Salinas • 831-755-0600 • Fax 831-758-8155 (MRI)

559 Abbott Street, Salinas • 831-775-5200 Fax 831-796-3891 (OPEN MRI)

26542 Carmel Rancho Blvd. Carmel • 831-625-7255 • Fax 831-625-7250 (MRI & US)

Please fax completed form, copy of insurance card, pertaining history and physical to Salinas or Carmel location selected above.

U AUTHORIZATION ASSISTANCE REQUESTED

MRI REQUESPatient: Last Name, First (printed) Date

Special Instructions

T Request Date

Df Birth Patient Telephone Number

Q STAT PHONE Call Back Number a STAT FAX a Send CD w/Patient

Referring Physician / Signature CC:

Date and Time of Appointment Name of Insurance

DIAGNOSIS / HISTORY

MRI PROCEDURES ORDERED(EXAMS AVAILABLE AT ALL LOCATIONS)

J 3D RECONSTRUCTION REQUIRED BODY

HEAD, NECK & SPINE Q AdrenalsJ Brachial Plexus J L J R

Q Brain 0 ChestQ1ACS a LiverQ Orblts a Renal/KidneyQ Parotid a MRCP/Pancreasa Pltultary a Multiple Myeloma Screening (SALINASasinuses a Oncology Whole Body (SALINAS ONL'0 Soft Tissue Neck a Bony Pelvis & Hips QL Qa Cervical Spine a pe|vic F|oor (|ncontinence)

a Thoracic Spine ID Pelvis - Soft Tissue0 Lumbar Spine LD Prostate

(D Penis_) Scrotum

J ArthrogramSitefMRIA

Physician Telephone Number

Company/ Prior Authorization Number

•

CONTRAST (circle one) Y N IF NEEDED

EXTREMITIES

a Finger ID L J RID Hand ID L ID RID Wrist ID L ID RID Forearm J L ID RID Elbow ID L ID R[D Shoulder ID L ID R

iONLY) ID Foot JL JR0 (D Ankle ID L ED RR ID Tibia/Fibula [D L ID R

Q Knee ID L ID RID Thigh ID L (D RID Hip ID L ID R

•throgram Fluoro Guided)

BREAST MRI ID EVALUATION OF MASS ID HIGH RISK SCREENING OR SURVEILLANCE

(559 ABBOTT ONLY) Q EVALUATION OF IMPLANT ID OTHER

MRA PROCEDURES ORDERED (with 3D RECONSTRUCTION)

HEAD BODY CARD|AC

(626 BRUNKEN ONLY) ID ViabilityID Intracranial (Circle of Willis) ID Abdominal Aorta & Lower Ext. Runoff Q perjcar(jjtjsQ Extracranial (Carotids) ID Mesenteric a cardiomyopathyJ MRV Brain J Renal j ARVD

a Thoracic Aorta a VALVE (circle one)J Upper Extremity J R J L Aortica MRV Pelvis Tricuspid

Mitral

Pulmonary

Other (please specify):

SALINAS PRESS FORM #519 PLEASE BRING THIS FORM WITH YOU ON THE DAY OF YOUR EXAM

ABOUT YOUR MRI EXAM:Magnetic Resonance Imaging (MRI) uses a strong magnetic field and radio waves to produce pictures of internal bodystructures. MRI is a painless procedure that uses no X-rays or radiation. An MRI scanner produces cross-sectional imageswhich allow physicians to see internal structures in great detail. Because of the magnetic field, patients with cardiacpacemaker, cerebral aneurysm clips, or ear implants may not be scanned.

BEFORE THE EXAM: Fasting is not required before your MRI exam. You may eat and drink as usual. If you are takingany medications, especially pain medication, take them as you normally would. You should wear comfortable clothingwith no metal, or a gown will be provided for you to change into.

THE EXAM: A magnetic resonance examination is a simple and safe procedure. You will be asked to remove watches,jewelry, credit and ATM cards, coins and any other metallic objects from your possession. A technologist will explain thetest to you then ask you to lie down on a padded table. The table will slide forward, positioning the part of your bodybeing scanned into the center of the magnet. The machine will make loud knocking noises during the imaging sequences.Ear plugs or headphones will be provided for your comfort.

Typical exam times range between 20 and 30 minutes, although some exams may take longer. The most important part ofthe exam for you is to lie very still. This is crucial because the scanner is very sensitive, and any movement during thesequences will blur the pictures, degrading the diagnostic quality of the examination.

Occasionally, a contrast agent is used. This is a substance that enhances the sensitivity of the images. This contrast mayhelp the radiologist interpret the images from your exam under certain circumstances. If needed, this will be injected into avein in your arm.

AFTER THE EXAM: Following the exam, you may leave. There are no after effects from MRI. The images are thenprocessed for interpretation by the radiologist. The results are not immediately available. The radiologist will contact yourphysician to convey the information ascertained from the scan. Please call your referring doctor for test results.

Some of the following items may exclude you from having an MRI exam. Please contact the Radiology Department at (831) 625-7255 (Carmel), or(831) 755-0600 (Salinas) if any of these apply to you, or if you have any questions.

I HAVE UNDERSTOOD AND ANSWERED ALL THE ABOVEN n Any History of Cancer? If so, what type & when

diagnosedY nY nY nY n

ELIGIBILITY QUESTIONS.

N

N

N

nnn

n

Previous C.T. of area to be scanned - if "yes," dateand what facility

Previous MRI of area to be scanned - if "yes," dateand what facility

Patient's Signature:

Date

Technologist's Comments:

Previous X-ray films of area to be scanned - if "yes,"date and what facility

Previous surgery of area to be scanned - if "yes,"date and what facility

CONTRAINDICTIONSY

Y

Y

Y

Y

Y

Y

nnnnnnn

N

N

N

NN

N

N

nnn

nnnn

PacemakerAneurysm Clips (Brain only) - if "yes," what type andphysician

History of metal in eye - metal worker - if "yes,"schedule Orbit X-rays before scheduling MRIPregnancy - must discuss with Radiologist

Are you breast feeding

Cochlear Implant - Inner Ear

Recent arterial stents

ELIGIBILITY CRITERIAY

YYY

Y

Y

Y

Y

YYYY

nnn

nnnnnnn

N

NNN

NN

N

N

NNNN

nnnnnnnnnnnn

Claustrophobic - if sedation is used, patient willneed to bring someone to drive them homeIs patient able to lie flat for an 1/2 hourIs there any metal in/on patient's body - if "yes,"locationSurgical ClipsMetallic IUDMiddle Ear Prosthesis/Hearing Aid/Hearing DeviceEyes Lens Implant/Artificial Eye

Implant

Implanted Neurostimulator/Biostimulator (Tens Unit)

Artificial Limb/Joint Prosthesis

Epilepsy or SeizuresEye Makeup/Eye TattooDentures/Partials

TO MONTEREY

CARMEL VALLEY ROAD

Cirmel RlnchoShopping Onwr

Coastal Valley Imagingof Carmel

(26542 Carmel Rancho Boulevard)

SALINAS PRESS FORM