PATI

ENT

INFO

RMAT

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& L

ATER

ALIT

Y

INDICATE AREAS OF CONCERN

SCREENING (WITH ADDITIONAL VIEWS AND/OR US IF NECESSARY)

DIAGNOSTIC (WITH ADDITIONAL VIEWS AND/OR US IF NECESSARY)

PICK ONE BILATERAL / RT OR LT

CONTRAST ENHANCED SPECTRAL MAMMOGRAPHY (CESM)

BUN/CREATININE (FOR CONTRAST EXAMS ONLY)

BRCA1 / BRCA2 GENE TESTING GALACTOGRAPHY

BREAST ULTRASOUND PICK ONE BILATERAL / RT OR LT

ULTRASOUND

ULTRASOUND BREAST BIOPSY

STEREOTACTIC BREAST BIOPSY

MRI-GUIDED BREAST BIOPSY

BREAST CYST ASPIRATION

MRI

PROCEDURES

MRI BREAST RAPID SCREENING BREAST MRI - DENSE BREASTS ONLY (WITH NO OTHER PROBLEMS(WITH NO OTHER PROBLEMS( )

BUN/CREATININE (FOR CONTRAST EXAMS ONLY)

PATI

ENT

INFO

RMAT

ION

&LA

TERA

LITY

INDICATE AREAS OF CONCERN

ULTRASOUND

MRI

PROCEDURES

SIGNATURE STAMPS ARE NOT VALID

(PLEASE INCLUDE LATERALITY, SPECIFIC SITE)

THIS SECTION MUST BE FULLY COMPLETED FOR ACCURACY, OR AN RMI EMPLOYEE WILL NEED TO CONTACT YOU PRIOR TO YOUR PATIENT’S EXAM.

PATI

ENT

INFO

RMAT

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PLEASE CALL FOR AN APPOINTMENT ON ALL EXAMS BELOW

EXAM PREPARATIONSCHEDULE YOUR EXAM

Flint Main: (810) 732-19193346 Lennon Rd. Flint, MI, 48507

Villa Linde: (810) 732-19195059 Villa Linde Pkwy, Suite 25, Flint, MI 48532

Fenton: (810) 732-1919221 W. Roberts St Fenton, MI 48430

Grand Blanc: (810) 732-19198483 Holly RdGrand Blanc, MI 48439

Davison: (810) 732-19191141 S. State Rd, Suite 26Davison, MI 48423

Lapeer: (810) 969-47001794 N. Lapeer Rd, Suite BLapeer, MI 48446

Novi: (248) 536-041024285 Karim Blvd, Suite ANovi, MI 48375

Royal Oak: (248) 543-722626454 Woodward Ave, Suite ARoyal Oak, MI 48067

Southgate: (734) 281-660015300 Trenton Rd.Southgate, MI 48195

INDICATE AREAS OF CONCERN

ULTRASOUND

MRI

PROCEDURES

BONE (DEXA) DENSITOMETRY

(3D TOMOSYNTHESIS IS AVAILABLE AT LENNON RD. FLINT AND NOVI LOCATIONS ONLY)

2D MAMMOGRAM (3D TOMOSYNTHESIS IF NECESSARY)

SCHEDULING Phone Fax n PRE-REGISTRATION Phone Fax

BREAST IMAGING FORM

rmipc.net

VILLA LINDE n FENTONnFLINT MAINn GRAND BLANCn DAVISONn LAPEERn NOVIn ROYAL OAKn SOUTHGATEn

BONE (DEXA) DENSITOMETRY

MAMMOGRAM (3D TOMOSYNTHESIS)

PRINT NAME VALID SIGNATURE STAMPS ARE NOT VALID

(PLEASE INCLUDE LATERALITY, SPECIFIC SITE)

THIS SECTION MUST BE FULLY COMPLETED FOR ACCURACY, OR AN RMI EMPLOYEE WILL NEED TO CONTACT YOU PRIOR TO YOUR PATIENT’S EXAM.

MEDICARE PATIENTS ONLY: BY LAW this section MUST be completed by the referring physician for Medicare advanced imaging: CT, MR, NUC, PET.

DSN #: AUC score: HCPCS modifier (circle one):

CDSM: Date/time CDSM was consulted:

PLEASE CALL FOR AN APPOINTMENT ON ALL EXAMS BELOW

(See back for office addresses)FENTON

GRAND BLANC LAPEER NOVI

ROYAL OAK

SOUTHGATE

LENNON RD, FLINT

VILLA LINDE, FLINT

BURTONDAVISON

rmipc.net

BREAST IMAGINGFORM

GENESEE COUNTY SCHEDULING Phone Fax

NOVI SCHEDULING Phone Fax

ROYAL OAK SCHEDULING Phone Fax

SOUTHGATE SCHEDULING Phone Fax

BONE (DEXA) DENSITOMETRY L-S SPINE/HIP WRIST/FOREARM

MAMMOGRAM (3D TOMOSYNTHESIS)

Patient Name: ____________________________________ DOB: ____/_____/_____ Gender: M F Weight: ______ Height: ______ Age: _______

Patient Phone #: (_____)___________________________

Ordering Physician: _____________________________________ Signature: ____________________________________ Date: _____/_____/_______Ordering Physician: _____________________________________ Signature: ____________________________________ Date: _____/_____/_______Ordering Physician: _____________________________________ Signature: ____________________________________ Date: __PRINT NAME VALID SIGNATURE STAMPS ARE NOT VALID

Symptoms/reason for exam: (PLEASE INCLUDE LATERALITY, SPECIFIC SITE)______________________________________________________________________

Other medical conditions RELEVANT TO THIS IMAGING STUDY_______________________________________________________________________________

Pre-Authorization number: ______________________________________________ Date range: ___________________________________________________________________

Physician preference for results: Routine STAT Hold Patient Release Patient

Call report #: (_____)________________________________________ Fax #: (_____)______________________________________________ CC: Doctor: ________________________________________________ Other: ___________________________________________________________

THIS SECTION MUST BE FULLY COMPLETED FOR ACCURACY, OR AN RMI EMPLOYEE WILL NEED TO CONTACT YOU PRIOR TO YOUR PATIENT’S EXAM.

MEDICARE PATIENTS ONLY: BY LAW this section MUST be completed by the referring physician for Medicare advanced imaging: CT, MR, NUC, PET.

DSN #: _________________________ AUC score: _______________________ HCPCS modifi er (circle one): ME MF MG MH

CDSM: Careselect OR other:Careselect OR other:Careselect ___________________ G - ___________________ Date/time CDSM was consulted: ________________________________

PLEASE CALL FOR AN APPOINTMENT ON ALL EXAMS BELOW

RMI-0031 (6-20)

(See back for offi ce addresses)

Appt. Date _____________

Appt. Time ____________

Arrival Time ___________

Location ______________

AMAppt. Time ____________PMAppt. Time ____________

rmipc.net

BREAST IMAGING FORM

GENESEE COUNTY SCHEDULING PHONE (810) 732-1919 FAX (810) 732-1945FAX (810) 732-1945 FAX

NOVI SCHEDULING PHONE (248) 536-0410 FAX (248) 536-0420ROYAL OAK SCHEDULING PHONE (248) 543-7226 FAX (248) 399-7226SOUTHGATE SCHEDULING PHONE (734) 281-6600 FAX (734) 281-7481

ONLINE SCHEDULING NOW AVAILABLE!In lieu of filling out this form, you can now schedule your appointment online at: https://rmi.opendr.com/For advanced access to your patient’s information and scheduling chart at no cost to you, follow this link: https://www.rmipc.net/online-scheduling-access/

to

MRI/MRA

• Call us immediately if you have a pacemaker, defi brillator, aneurysm clips, or if you are pregnant, have a history of metal in your eyes, or have had brain, eye, ear, open heart surgery or internal stimulation devices.

• Our MRI scanner is specially designed to signifi cantly decrease the problem of claustrophobia. Do not hesitate to discuss this issue with your doctor prior the examination.

• It is suggested that you wear sweat suits or similar comfortable clothing.

• Gown will be provided

DIRECTIONSPlease follow instructions below. Proper preparation is important for good examination and your personal comfort. Please bring this form, photo ID, medical insurance, and a complete list of all current medications with you at the time of your examination.

(810) 732-1919(810) 969-4700

Genesee Area Lapeer Area

Novi AreaRoyal Oak AreaSouthgate Area

(248) 536-0410(248) 543-7226(734) 281-6600

MAMMOGRAM PREP• Please refrain from using deodorants, perfumes, powders or lotions before the mammogram.

They may interfere with the quality of your test.

• Compression of the breast is a critical part of the study. If your breasts are sensitive before the screening, you may choose to reschedule your mammogram, or schedule it a week afteryour period.

• Please tell the technologist if you experience soreness during the examination. She will makeappropriate adjustments to ensure your comfort.

BIOPSY PREP• Choose comfortable, loose-fi tting clothing to wear on the day of the exam. You can also expect to

wear a gown that RMI will provide, and you may need to remove any jewelry or accessories thatcould interfere with the exam. For MRI biopsy, you should also inform us before scheduling yourappointment if you have any metallic surgical implants or accidentally implanted metallic objects

• To numb the breast so that you will feel little or no sensation when the biopsy needle is inserted,you will receive a local anesthetic.

• We may recommend that you use a cold pack and over-the-counter pain medications to relieveany discomfort from mild swelling or bruising after the procedure. You should avoid strenuousactivity for the fi rst 24 hours, but you should otherwise be able to resume a normal routine.

EXAM PREPARATION

Please follow the instructions below. Proper preparation is important for a good examination and your personal comfort.your personal comfort.your personal comfort