MRI Patient Screening and History
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- Iris Jordan
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1 Griffin Imaging, LLC 220 Rock Street Griffin, GA (770) Fax:: (770) Specializing In Open MRI, CT & Ultrasound MRI Patient Screening and History Patient Information Sheet PATIENT NAME: AGE: WEIGHT: SEX: MALE FEMALE REFERRED BY DOCTOR: AREA OF CONCERN: SPECIFIC INSTRUCTIONS: SMOKER or NON SMOKER Patient History PREVIOUS MRI/CT OR X-RAY? YES NO EXAMINATION: DATES: LOCATION: _ HAVE YOU EVER BEEN DIAGNOSED WITH CANCER? YES NO PLEASE EXPLAIN: PREVIOUS SURGERY: HEAD: NECK: CHEST: ABDOMEN: EXTREMITIES: OTHER:
2 The following items can interfere with MRI imaging and some may be hazardous to your safety. Please check if you have any of these items: Pacemaker Brain Clips Brain Aneurysm Clips Cochlear Implant (Ear) Aortic Clips Neurostimulators Artificial Heart Valve Insulin Pump Electrodes Hearing Aids IUD Shunt Spinal or Ventricular Joint Replacements Fractured Bones Treated with Metal Rods Metal Plates, Pins, Screws, Nails, or Clips Harrington Rods Bone or Joint Pins Prosthesis Metal Mesh Implant Wire Sutures Shrapnel Dentures Metal Fragments in Head, Eyes or Skin Are you currently on dialysis? Are you in the first trimester of pregnancy? _ Have you had brain surgery? If so, when? Have you had any surgery or injury where metal objects could still be in your body? If so, when? _ Any other implants? (Please Explain) I understand that some studies of the head or spine may require a special contrast material to be injected into the bloodstream to improve the accuracy of our study. This drug is considered safe, however a small number of patients may experience an allergic reaction. I have read and understand the above and give consent for this exam and the injection of contrast if necessary. Patient/ Legal Guardian
3 Witness Griffin Imaging, LLC 220 Rock Street Griffin, GA (770) Fax:: (770) Specializing In Open MRI, CT & Ultrasound MRI Consent Form Patient Name: Social Security #: : INTRODUCTION Unlike CAT scanning (CT) and some other methods of viewing the body, Magnetic Resonance Imaging (MRI) does not use x-rays but rather uses magnetism and radio waves. As far as we know, M.R.I. is safe. Millions of patients have already been imaged worldwide without apparent difficulty. PROCEDURE RISKS You will be interviewed to be certain that you do not have a pacemaker or other implanted electronic device. If you have had brain surgery we must obtain (or you must provide) an x-ray of your head to be certain metallic aneurysm clips were not used. If there is any chance of pregnancy, please inform the technologist prior to the exam. Is there any possibility of pregnancy? Please initial You will be asked to remove your clothes, watch, jewelry (rings excepted), and to change into a hospital gown. A small locker will be provided for your valuables. You will enter the scan room and lie on a table that will slide you into the magnet. This is the M.R.I. magnet. Although you will hear repetitive machine-like noise, you will feel nothing abnormal. Ear plugs will be provided. You will be asked to lie still approximately thirty minutes to an hour, or less. You will be asked to allow us to access your medical records and other diagnostic examinations for purposes of comparison. In certain cases a magnetic contrast agent may be indicated. If this is necessary you will be informed in advance. Extensive evaluation has shown no hazardous effects from M.R.I. Because this is still a relatively new technology, however, long-term effects are unknown. Steps have been taken to exclude metallic objects from the M.R.I. suite. Your doctor has asked that you have an exam that involves Magnetic Resonance Imaging of the body. This method of examination has the possibility of better defining certain tissues within the body and may improve the diagnostic capability with little known risks to you. If magnetic contrast is injected, the risks of an allergic reaction (i.e., hives, itching, low blood pressure, headaches, and nausea) are present. Although very rare, a few fatalities have been reported in the medical literature. We will take all steps necessary to handle any reaction that might occur, however, there can be no guarantee regarding the success or results of such treatment. By signing below, I attest that I have read and understand all of the above and I agree to being scanned by Griffin Imaging, LLC. I have reviewed all of my answers for accuracy and have had the opportunity to ask any questions regarding the information on this form and the examination that I am to undergo. Signature of Person Completing the Form: : Form Completed By: Patient Relative Nurse _ (Name) _
4 Form Information Reviewed By: (Print Name) (Signature) PATIENT HISTORY AND SAFETY SCREENING Please check any of the below items if applicable to you: History of allergic reaction to X-ray/IVP/iodinated dyes or contrasts Allergy to other medications Other allergies Asthma, any form Sickle Cell Anemia Kidney failure High Blood Pressure (Hypertension) Diabetes (High Sugar) Pacemaker/ Defibrillator Neurostimulator Possibility of Pregnancy? Hearing Aids Any other Mechanical Implants not listed above: Is your scan today part of any clinical research study associated with the Center for Medicare and Medicaid Services? Yes or No _ Patient / Legal Guardian Witness
5 PATIENT CONSENT Use/ Disclosure of Health Care Information Patient s Name: SS#: of Birth: Previous Name: I understand that the patient s health information is private and confidential. I understand that Griffin Imaging, LLC works very hard to protect the patient s privacy and preserve the confidentiality of the patient s personal health information. I understand that Griffin Imaging, LLC and it s employee s may use and disclose the patient s personal health information to help provide health care to the patient, to handle billing and payments, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. These situations are very unusual. Griffin Imaging, LLC has a detailed document called the Notice of Privacy Practices. It contains more information about the policies and practices protecting the patient s privacy. I understand that I have the right to read the Notice before signing this agreement. Griffin Imaging, LLC may update this Notice of Privacy Practices. If I ask, Griffin Imaging, LLC will provide me with the most current Notice of Privacy Practices. Under the terms of this consent, I can ask Griffin Imaging to limit how the patient s personal health information is used or disclosed to carry out treatment, payment or health care operations. I understand that Griffin Imaging, LLC does not have to agree to my request. If Griffin Imaging, LLC does agree to my request, I understand that Griffin Imaging, LLC would follow the agreed upon limits. I may cancel this consent in writing at any time by doing one of the following: Signing and dating a form that Griffin Imaging, LLC can give to me called a Revocation of Consent for Use and Disclosure of Health Care Information, or Writing, signing, and dating a letter to Griffin Imaging, LLC. If I write a letter, it must state that I want to revoke my consent to authorize the use and disclosure of the patient s personal health information for treatment, payment and health care operations. If I revoke this consent, Griffin Imaging, LLC does not have to provide any further health care services. My signature below indicates that I have been given the opportunity to review a current copy of Griffin Imaging, LLC Notice of Privacy Practices. My signature means that I agree to allow Griffin Imaging, LLC to use and disclose the patient s personal health information to carry out treatment, payment and health care operations. Please indicate phone number where we can leave confidential information: List any other individual we are allowed to speak with: Regarding my bill (only) Regarding testing results (only) Regarding both Patient or legally authorized individual signature Time Relationship to patient if signed by anyone other than patient (parent, legal guardian, etc.)
6 Witness Time Specializing In High Field MRI, CT, Ultrasound & Bone Density Scans Rock Street Griffin, GA (770) Fax: (770) RECORD RELEASE FORM I hereby request and authorize Griffin Imaging, LLC to obtain copies of my medical records and/or x-ray films from. Patient Name: of Birth: SSN: Pt Acct #: Exam: of Service: Referring Phys.: Please fax any and all records pertaining to the above listed date of service and exam to Griffin Imaging, Attention: Dr. Ronald C. Gay at (770) Patient Signature Witness
7 220 Rock Street Griffin, GA REQUEST FOR CONFIDENTIAL COMMUNICATION PROTECTED HEALTH INFORMATION Patient Name: _ of birth: Has requested confidential communication of protected health information Designated Contact Person(s) for this Patient: Communications about the patient names above should only be directed to: Name: Relationship to Patient Phone Number: At times, this office may need to contact you concerning appointments, radiology results, etc. If you have an answering machine or voice mail, is it permissible to leave your health information on your answering machine or voice mail? Yes No Patient Signature
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716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone
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