Your Appointment Date:­____/_____/_____

Time:­_________❑ am ❑ pmPlease Bring:­ Doctor’s Prescription, Insurance Card/Info,

and Photo ID. If you must change your appointment, please give

at least 24 hours’ notice.

❑ Lynbrook229 Broadway(516) 256-1558Fax:­ (516) 256-0758 NPI:­ 1134211436

❑ Carle Place31 Old Country Rd.(516) 746-2248Fax:­ (516) 746-2218 NPI:­ 1295826584

❑ Wantagh1165 Wantagh Ave.(516) 781-1800Fax:­ (516) 781-1888 NPI:­ 1982942272

❑ Melville110 Marcus Drive(631) 454-0539Fax:­ (631) 454-9190 NPI:­ 1457326506

❑ Deer Park1118 Deer Park Ave.(631) 243-3222Fax:­ (631) 243-3355 NPI:­ 1821180159

❑ Islandia1824 Vets Mem. Hwy.(631) 348-0996Fax:­ (631) 348-0997 NPI:­ 1427024199

❑ East Setauket24 Research Way(631) 444-5361Fax:­ (631) 444-5362 NPI:­ 1124093018

MULTI-POSITION MRI

LUMBAR

Patient’s Name:________________________________________________Phone:(_____)_______________Date of Referral:_____/______/_____ First MI Last

Chief Complaint(s):________________________________________________________________________________________________________

Surgical History:__________________________________________________________________________________________________________

Doctor’s Name:_______________________________________________________Doctor’s Signature:__________________________________

Address:______________________________________________________________

Phone:____________________________Fax:________________________________

CERVICAL Add-On Positions (Optional)

w/o❑ 72141

w & w/o❑ 72156

❑ Flexion ❑ Extension

❑ Recumbent (for comparison)

❑ Other __________________________

THORACIC

w/o❑ 72146

w & w/o❑ 72157

Add-On Position (Optional)❑ Recumbent

(for comparison)

UPPER EXTREMITIES / JOINTS w/o w & w/o❑ Shoulder ❑ L ❑ R ❑ 73221 ❑ 73223❑ Humerus ❑ L ❑ R ❑ 73218 ❑ 73220❑ Elbow ❑ L ❑ R ❑ 73221 ❑ 73223❑ Forearm ❑ L ❑ R ❑ 73218 ❑ 73220❑ Wrist ❑ L ❑ R ❑ 73221 ❑ 73223❑ Hand ❑ L ❑ R ❑ 73218 ❑ 73220

Other / Special Instructions:___________________________

LOWER EXTREMITIES / JOINTS w/o w & w/o❑ Hip ❑ L ❑ R ❑ 73721 ❑ 73723❑ Femur ❑ L ❑ R ❑ 73718 ❑ 73720❑ Knee ❑ L ❑ R ❑ 73721 ❑ 73723❑ Tib/Fib ❑ L ❑ R ❑ 73718 ❑ 73720❑ Ankle ❑ L ❑ R ❑ 73721 ❑ 73723❑ Foot ❑ L ❑ R ❑ 73718 ❑ 73720

Other / Special Instructions:___________________________

HEAD Routine Brain Brain/Attn: IACs Brain/Attn: Pituitary IACs Pituitary TMJ ❑ L ❑ R

w/o ❑ 70551 ❑ 70551 ❑ 70551 ❑ 70551 ❑ 70551 ❑ 70336

w & w/o❑ 70553❑ 70553❑ 70553❑ 70553❑ 70553❑ none

Add-On Positions (Optional)

w/o❑ 72148

w & w/o❑ 72158

BODY

Region of Interest :___________________________________________

Please Specify: ❑w/o ❑w & w/o

VERY IMPORTANT: If you have a pacemaker OR ever had metal in your eye or somewhere else in your body OR you wear a medication patch OR you might be pregnant, you must notify us before you come for your appointment.

Clinical Indications / Symptoms:_________________

________________________________________________

________________________________________________

________________________________________________

❑ Flexion ❑ Extension

❑ Recumbent (for comparison)

❑ Other __________________________

ORBIT / FACE / NECKOrbits Sinuses Soft Tissue Neck

❑ 70540 ❑ 70540 ❑ 70540

❑ 70543❑ 70543❑ 70543

MRA ❑ Circle of Willis w/o 70544 / ❑ Carotid Arteries w/o 70547

Other / Special Instructions: ________________________________________

Special Instructions: ____________________________

Give ❑ CD ❑ Films ❑ Imagegram to my patient.

Send ❑ CD ❑ Films ❑ Imagegram to my office. (Note: Cutaway views are provided below to show patient positioning.)

❑Great Neck600 Northern Blvd.(516) 478-0004Fax:­ (516) 478-0013 NPI:­ 1568828861

PRINTED

FROM

WEBSITE

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