ࡱ> 463 bjbjII 4"++{3VV&&&&&:::8r4:R,v&*&&4 ***^&&***8@ oQT"0R$ *$ *&*R$ V :    Acct #: Patient Name: DOB: Weight: Allergies: ( ) Orbital Screening Study Ordered ( ) Electronic Implant MRI Staff Contacted ( ) Orbits ( ) Sedation required ( ) Creatinine Ordered ( ) Previous Back Surgery If the patient has a Defibrillator, Cardiac Pacemaker or Dorsal Column Nerve Stimulator you may NOT schedule an MRI. If the patient has or has ever had a Cardiac Pacemaker removed you may NOT schedule an MRI. If the patient has a Cerebral Aneurysm Clip, please contact the MRI staff prior to proceeding. ***************************************************************************************************** ( ) MRI ( ) MRA ( ) With Contrast ( ) Without Contrast ( ) With & Without Contrast Procedure (if indicated) Intra-articular Joint Injection under Fluoroscopy Medication/Dosage: Diagnosis: ICD-10 Special Instructions: DATE OF EXAM: Arrival Time: Scan Time: Ordering Physician: Date: *************************************************************************************************************** PATIENT INSTRUCTIONS ( ) If you are having an Intra-articular Joint Injection, receiving contrast as a part of your MRI, having an MR Arthrogram or if you are claustrophobic, you will need someone to drive you home. ( ) If you are having a Lumbar Spine MRI, do not eat or drink anything three (3) hours prior to your procedure. ( ) If you are having an arthrogram, do not eat or drink anything four (4) hours prior to your procedure. ( ) If you have ever worked with metal or had metal in your eye you will need x-ray screening (orbits) prior to the procedure. ( ) Return Appointment Date Time Location ( ) The patient has been given a copy of the MRI Disclosure Statement     MRI Order Mriorder.12.30.10    !"'),-345678DPQRwyǹǹǣrfǀfǀ]Thf5CJaJhU5CJaJhOhh5CJaJhOh5>*CJaJhOh5CJaJhvKhEK5>*CJaJhvK5CJaJhvK5>*CJaJhl5>*CJaJhOhEK5>*CJaJhOhEK5CJaJhhCJaJhCJaJhlhEK>*CJaJhl>*CJaJhlCJaJ  8Q   F G ! u `dh]^`gd`dh]^`gdEK$`]^`a$gdO `]^`gd"`dh]^`gd" `]^`gdEK    & k l t v E F G 㿶}um}m}mbm]UIhOhO5CJaJhOhO6 h-16hOh"CJaJhOh"6hOh1V6 hO6hOh*CJaJ ! " + : \ ` v y ŷӝӑvvmbbYhH$5CJaJh"5>*CJaJh5CJaJh1V5CJaJhvK5CJaJh"5CJaJhhh5CJaJhh5CJaJhh5>*CJaJhh75>*CJaJhhEK5>*CJaJhhEK5CJaJh$g5CJaJh$gCJaJh*CJaJhOh75>*CJaJhOhEK5>*CJaJhOhEK5CJaJhOhmo5CJaJhOh56>*CJaJhOh56CJaJhOh5CJaJhOhEK5>*CJaJhOhEK5CJaJhCJaJhh5>*CJaJh"5>*CJaJh"5CJaJ 1 J Q X o p  vwx$&0239\z{|~ǿϬxtxtxtxtplhJ#hh jh UhXhXCJaJhjCJaJhq>*CJaJhqCJaJhCJaJhXCJaJh-1hhCJaJhhCJaJh-1CJaJh-1h-1CJaJh-1hCJaJhmoCJaJhr `С-;c=1g~'}xPiB$IO1Êk9IcLHY<;*v7'aE\h>=^,*8q;^*4?Wq{nԉogAߤ>8f2*<")QHxK |]Zz)ӁMSm@\&>!7;wP3[EBU`1OC5VD Xa?p S4[NS28;Y[꫙,T1|n;+/ʕj\\,E:! t4.T̡ e1 }; [z^pl@ok0e g@GGHPXNT,مde|*YdT\Y䀰+(T7$ow2缂#G֛ʥ?q NK-/M,WgxFV/FQⷶO&ecx\QLW@H!+{[|{!KAi `cm2iU|Y+ ި [[vxrNE3pmR =Y04,!&0+WC܃@oOS2'Sٮ05$ɤ]pm3Ft GɄ-!y"ӉV . `עv,O.%вKasSƭvMz`3{9+e@eՔLy7W_XtlPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-!pO[Content_Types].xmlPK-!֧6 -_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!!Z!theme/theme/theme1.xmlPK-! ѐ'( theme/theme/_rels/themeManager.xml.relsPK]#  " .025  u  @ @H 0( ltnc ltnc  0( 6 B S  ?&0{}~RV9A x|37{}~::::::::::::Ҙ ^`OJQJo( 8^8`OJQJo(^`OJQJ^Jo(o  p^ `OJQJo(  @ ^ `OJQJo( x^x`OJQJo(H^H`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(32<&#Z8H$ W0-1`#6fIEK;RUW~zZYGb$gImomomohhvKfab(7i