Physician Order Form

Patient Name: ____________________________________________________DOB:______/________/_______

Patient Primary Phone: _____________________________________ Height: __________ Weight: ___________

Symptoms: ________________________________________________________________________________

Suspected Diagnosis (HNP, mass, tear, etc):________________________________________________________

Insurance Provider: _________________________________ Authorization #/CPT Code: ___________________

Urgency: q STAT – Fax report to: ______________________ q Routine q CD to go

PRINT ordering clinician’s name: ________________________________________________________________

SIGNATURE of ordering clinician: _______________________________________________________________

MRI PROCEDURE Exam Requested

CONTRAST – PLEASE CHECK ONE:

q With q Without q With/Without

q MRI Neck

q Neck for soft tissue (structures other than C-spine)

q MRI C-Spine

q MRI T-Spine

q MRI L-Spine

q Bony Pelvis

q SI JTS/Sacrum/ or Coccyx

q Brachial Plexus

q MRI Wrist q Left q Right

q MRI Elbow q Left q Right

q MRI Shoulder q Left q Right

q MRI Knee q Left q Right

q MRI Hand q Left q Right

q MRI Hip q Left q Right

q MRI Ankle q Left q Right

q MRI Foot q Left q Right

q MRI Brain

MRI Other_______________________________

Musculoskeletal MRI muscles • tendons • ligaments

bones • soft tissues • joints

A serum creatinine level and BUN is needed within the last 30 days if the patient can answer yes to any of the following:q Age 50 years or over q Labs have been orderedq Diabetes q Hypertension q Liver Disease q Kidney Disease

Please fax your lab results to 603-743-3191

www.sosmed.org

Contrast MRI Exam Requirement

If you are interested in ordering an MRI for your patient, please complete and fax this MRI order form along with the patient’s insurance card to 603-743-3191 or please call MRI scheduling at 603-742-1285 x397.

7 Marsh Brook Drive • Somersworth, NH 03878 • 800-429-5002MRI PHONE 603-742-1285 x397 • FAX 603-743-3191

Thank you for your referral. To request more forms, call 603-742-1285 x397. Extended hours available.

How do I prepare for an MRI exam?Preparing for your MRI exam is easy:• There are no specific preparations needed. You may go about your normal activities and take your routine medications unless instructed not to by your physician.

• Please plan on arriving at least 20 minutes prior to your scheduled time to register and complete paperwork.

• Once you have arrived and checked in, you will be met by one of our trained MRI Technologists who will review your paperwork, carefully screen you for conditions that may be problematic, and answer any questions you might have about your scan.

• Please tell your MRI Technologist before the MRI if you have a pacemaker, artificial heart valve, implanted drug infusion port, intrauterine device (IUD), or any pins, metallic implants, aneurysm clips, or metal fragments from previous injuries or surgeries.

• Before your scan, you may be asked to change into a gown/scrubs. No keys, coins, credit cards, dentures with metal components, hearing aids, jewelry, or cell phones are allowed inside the room where the MRI scan takes place.

• Your physician may have ordered a contrast agent for certain exams to enhance the images for interpretation. If so, an intravenous line (IV) will be started in your hand or arm.

How To Find Us...Our main office is located at 7 Marsh Brook Drive inthe Marsh Brook Professional Center on Route 108 in Somersworth, NH. (COAST Bus line Route #2). Take the Spaulding Turnpike to Exit 9. We are two miles north on Route 108 from Weeks Crossing. Our MRI Lab is located in Building C.

7 Marsh Brook Drive • Somersworth, NH 03878

Appointment Date: Appointment Time:

16

16

Rochester

Somersworth

Berwick

Dover

9

9

236

108

108

108125

108

236

Spaulding Turnpike

Old Dover Road

Pine Hill Road

Portland Ave

125

236

16

4

Main Phone 603-742-2007 • MRI 603-742-1285 x397 800-429-5002 • www.sosmed.org