Your Appointment: Date_____/_____/_____ Time________ ❑ am ❑ pm• Please Bring: Doctor’s Prescription, Insurance Card/Info and Photo ID• If you have a pacemaker or any metal object in your body, or if you wear a medication patch, or if you might be pregnant, please notify us before you come for your appointment.• If you must change your appointment, please give at least 24 hours’ notice.

Patient’s Name:________________________________________Patient's Phone:___________________Date of Referral:_______/_______/_______ First MI Last

Chief Complaint(s):________________________________________________________________________________________________________

Surgical History:__________________________________________________________________________________________________________

Doctor’s Name:_______________________________________________________Doctor’s Signature:_____________________________________

Doctor’s Address:______________________________________________________

Doctor’s Phone:____________________________Fax:________________________

1.5T MRI

Clinical Indications / Symptoms:_____________________

________________________________________________

A Note to Patients/Doctors Regarding MRI Contrast Studies: Blood work (in particular, the estimated eGFR) is needed for patients who are 60 years old or older OR are diabetic OR have kidney problems.

Blood Work must be done no earlier than six (6) weeks prior to the scheduled exam and the results must be sent to us prior to the appointment.

Give ❑ Films ❑ CD to my patient / Send ❑ Films ❑ CD ❑ Imagegram to my office.

X-RAY

MRA w/o w & w/oHead/COW ❑ 70544 ❑ 70546 Neck/Carotids ❑ 70547 ❑ 70549 Chest/Aorta ❑ 71555 ❑ 70549 Abdomen/Aorta/Renal ❑ 74185 ❑ 70549 Upper Extremity w/Runoff ❑ L ❑ R ❑ 73225 ❑ 70549 Lower Extremity w/Runoff (includes Abdomen and Pelvis) ❑ 74185 ❑ 73725

Other/Special Instructions: ____________________________________________

HEAD AND NECK❑ Skull ❑ Nasal ❑ Mandible❑ Facial/Orbit❑ TMJ❑ Orbit Clearance❑ SinusesOther/Special Instructions: __________________________________

EXTREMITIES / JOINTSUpper❑ Shoulder ❑ L ❑ R❑ Scapula ❑ L ❑ R❑ Clavicle ❑ L ❑ R❑ Humerus ❑ L ❑ R❑ Elbow ❑ L ❑ R❑ Radius/Ulna ❑ L ❑ R❑ Wrist ❑ L ❑ R❑ Hand ❑ L ❑ R❑ Finger #_____ ❑ L ❑ R❑ Thumb ❑ L ❑ RLower❑ Hip ❑ L ❑ R❑ Femur ❑ L ❑ R❑ Knee ❑ L ❑ R❑ Tib/Fib ❑ L ❑ R❑ Ankle ❑ L ❑ R❑ Foot ❑ L ❑ R❑ Toe #_____ ❑ L ❑ R

Other/Special Instructions: _____________________________________________________________

SPINE/TRUNK❑ C-Spine ❑ AP/Lat ❑ Flex/Ext ❑ Obliques❑ T-Spine❑ L-Spine ❑ AP/Lat ❑ Flex/Ext ❑ Obliques❑ Chest❑ Rib: ❑ L ❑ R ❑ Pelvis❑ Sacrum/CoccyxOther/Special Instructions: ____________________________________________

HEAD w/o w & w/oRoutine Brain ❑ 70551 ❑ 70553 (including Brain Stem)Pituitary ❑ 70551 ❑ 70553IAC’s ❑ 70551 ❑ 70553TMJ ❑ 70336 ❑ 70336

Other/Special Instructions:______________________________________________

ORBIT / FACE / NECK w/o w & w/oFace ❑ 70540 ❑ 70543 Orbits ❑ 70540 ❑ 70543Sinuses ❑ 70540 ❑ 70543Soft Tissue Neck ❑ 70540 ❑ 70543Brachial Plexus (Unilateral) ❑ 73218 ❑ 73220Brachial Plexus (Bilateral) ❑ 71550 ❑ 71552

Other/Special Instructions: ________________________________________________________

Upper Extremities/Joints w/o w & w/oShoulder ❑ L ❑ R ❑ 73221 ❑ 73223Humerus ❑ L ❑ R ❑ 73218 ❑ 73220Elbow ❑ L ❑ R ❑ 73221 ❑ 73223Forearm ❑ L ❑ R ❑ 73218 ❑ 73220Wrist ❑ L ❑ R ❑ 73221 ❑ 73223Hand ❑ L ❑ R ❑ 73218 ❑ 73220Finger #___ ❑ L ❑ R ❑ 73218 ❑ 73220Thumb ❑ L ❑ R ❑ 73218 ❑ 73220

Other/Special Instructions: _____________________________________________________________

Lower Extremities/Joints w/o w & w/oHip ❑ L ❑ R ❑ 73721 ❑ 73723Femur ❑ L ❑ R ❑ 73718 ❑ 73720Knee ❑ L ❑ R ❑ 73721 ❑ 73723Tib/Fib ❑ L ❑ R ❑ 73718 ❑ 73720Ankle ❑ L ❑ R ❑ 73721 ❑ 73723Foot ❑ L ❑ R ❑ 73718 ❑ 73720Toe #___ ❑ L ❑ R ❑ 73718 ❑ 73720

Other/Special Instructions: _____________________________________________________________

SPINE w/o w & w/oCervical ❑ 72141 ❑ 72156Thoracic ❑ 72146 ❑ 72157Lumbar ❑ 72148 ❑ 72158Sacrum/Coccyx ❑ 72195 ❑ 72197

Other/Special Instructions: ______________________________________________

BODY w/o w & w/oChest ❑ 71550 ❑ 71552Pelvis ❑ 72195 ❑ 72197MRCP ❑ 74181 ❑ 74183Abdomen ❑ 72181 ❑ 74183 ❑ Liver (Dynamic Contrast-Enhanced) 74182

Other/Special Instructions: __________________________________________________________

2050 Eastchester Road, Suite 1BBronx, New York 10461718.678.1970 • Fax: 718.678.1975www.standupmriofthebronx.com

1.5T MRI and X-RAY

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FROM

WEBSITE

MRI SAFETY PRECAUTIONS:Call ahead if you…• have a pacemaker • have a metal particle(s) in your eye(s), or ever had a metal

particle(s) removed from your eye(s)• are or think you might be pregnant• had heart surgery or surgery of the heart’s valves • had brain surgery• have or think you might have a metal object inside

your body

BRING the following with you when you come for your appointment:• Photo I.D.

• Insurance Information/Card

• A Written Doctor’s Order, Prescription or Script for Your MRI exam

• If you already had diagnostic images made of the region that we will be scanning (MRI scans or CAT scans), please bring copies of the report(s) and, if requested by the radiologist, copies of the films as well.

PREPARATION for your X-Ray Exam:In general, you undress whatever part of your body needs examination. You may wear a gown to cover yourself during the exam, depending on which area is being X-rayed. You may also be asked to remove jewelry, eyeglasses and any metal objects that may obscure the X-ray image, because these objects can show up on an X-ray.

WARNING: DO NOT BRING any of the following into the MRI Exam Room:

Why? Because an MRI scanner’s magnetic field…• can damage or completely destroy hearings aids, watches, cell

phones, PDA's, storage media, insulin pumps, electronic keys, etc.• can erase credit/debit cards • can launch metallic objects, creating a serious hazard to the patient.In general, metal objects of any size can degrade the quality of the MRI picture, possibly requiring you to return to repeat the exam.Please be advised that neither the owner of this practice nor the management company will be held responsible for any damages or losses resulting from a patient’s failure to comply with this warning.

• Hearings Aids• Watches• Cell Phones• PDA’s • Storage Media• Insulin Pumps• Keys

• Tablets/Laptops• Credit/Debit Cards• Wallets• Metal Objects• Hair Clips/Bobby Pins• Coins/Loose Change

PREPARATION for your MRI Exam:• For patients who are scheduled for an MRI scan with contrast:

If you are 60 or older OR diabetic OR have kidney problems, your blood work results must be sent to us in advance. Blood work must be done no earlier than six (6) weeks prior to your scheduled exam.

• Avoid wearing metal objects near the area to be scanned.

• Sweatsuits are advisable because they are comfortable and have very little metal in them.

• There are no food or drink restrictions.

• Take your regular medication(s), if any, as usual.

2050 Eastchester Road, Suite 1BBronx, New York 10461718.678.1970 • Fax: 718.678.1975From Pelham Parkway:Turn south onto Eastchester Road and travel for approximately 0.2 miles. The MRI facility will be on your left on the corner of Eastchester Road and Seminole Street, across from Jacobi Medical Center.

By Bus:BX 31 stops right in front.BX21 and BXM10 stop on the corner of Morris Park Avenue and Eastchester Road. It’s between a five and ten minute walk up Eastchester Road to the MRI facility.

Bronx - 1.5T / X-Ray

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