Facility Name: Patient Registration. Name: Address: Home: Work: Mobile: Race: Gender: Marital Status: Emergency Contact Information

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1 Facility Date: MRN/Jacket: Patient Registration Address: Home: Work: Mobile: Date of Birth: Race: Gender: Marital Status: SSN: Employer: Registered Location: Physician: Emergency Contact Information Relationship to Patient: Address: Home: Work: Mobile: Insurance Primary Insurance Plan Policy #: Group Group #: Secondary Insurance Plan Policy #: Group Group #: Relationship to Insured Other than Self Relationship to Patient: Self Address: Home: ( Work: DOB: Employment Status: Employer: Auto Accident or Worker s Compensation Information Is this injury due to accident? Yes No If yes, what type of Accident? Accident Date: Auto Insur Info: Accident State: Phone: Auto Insur Adrs: Zip: State: Zip: Case Manager or Adjuster s Phone:

2 Patient MRN/Jacket #: By signing below, I agree to the following for outpatient radiology care provided by Authorization for Treatment I hereby consent to and permit the attending physician and other medical staff to provide me treatment and care as may be deemed necessary and available to me during my office visit or outpatient procedure, including but not limited to tests, examinations, local anesthetics, x rays and medical and surgical treatments, and other necessary procedures. Release of Medical Information With this consent, may use and disclose my protected health information for treatment, payment and health care operations as explained in the Notice of Privacy Practices. I also authorize release of my protected health information to, the interpreting Radiologist group, government agencies (such as Medicare and Medicaid), insurance carriers, and other providers for treatment purposes. I understand that I may authorize a personal representative to have access to my protected health information as well. Financial Responsibility With this consent, I authorize and/or their representatives to review my insurance coverage with my insurance company. I request that payment of authorized benefits be made directly to on my behalf. I fully understand that I am financially responsible for any and all amounts not otherwise paid by my insurance carrier or worker s compensation. I also certify the information, on this form, given by me for payment under Title XVIII (Medicare) is correct and complete. Notice of Privacy Practices I acknowledge that I had the opportunity to review the Notice of Privacy Practices. I understand I may request a paper or electronic copy of this policy to keep. With this consent, may call or my home or other alternative location and leave messages or voice mail in reference to any items that assist them in carrying out treatment, payment and health care operations, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including test results, among others. I understand I may revoke my consent in writing except to the extent that has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it line to provide treatment to me. Signature: Date: Printed If you would like to authorize a personal representative to have access to your protected health information including your images, films and reports, please list the person's name, DOB and relationship below. Date of Birth: Relationship to Patient: Signature: Date:

3 Date: MRN/Jacket #: PATIENT HISTORY FORM Patient Gender: DOB: Age: Height: Feet Inches Current Weight: lbs Referring Physician: Procedure: Reason you are here today for an exam? Explain your medical problem in detail. Have you had a previous imaging study related to this problem (x-ray, ultrasound, CT, MRI)? If yes, please explain: What exam? When? Name of facility: List any drug or food allergies: List previous surgeries: Medications you are presently taking: Any other medical issues we should know about: Female Patients Only Is there any chance you may be pregnant? Date of last period: Are you breastfeeding? For Contrast Exams Only For Contrast Exams Only Have you ever had a previous allergic reaction to injected contrast during a CT, MRI, or X-Ray? If yes, explain: Any Personal History of: Seizure Disorder Stroke Asthma Liver Disease Multiple Myeloma Cancer If yes, please specify Heart Disease High Blood Pressure Blood Disorder/Sickle Cell Kidney Disease/Kidney Failure Dialysis Are you diabetic? Are you taking Metformin hydrochloride (Glucophage, Glucovance, Avandement, Metaglip, and Fortamet)? Patients with Diabetes If you are taking Metformin (Glucophage, Glucovance, etc.) and having a contrast injection in X-ray or CT today, you will be asked to stop taking it for 48 hours post injection of contrast media. Contact your primary physician prior to restarting your Metformin to make sure your renal functions are okay. I will stop my Metformin and contact my physician before restarting it. (Initial Here) Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me. If I am to have intravenous contrast with my procedure, I have been informed of the risks. I give consent to the performance of a/an Patient/Parent/Guardian Signature: Date:

4 Jacket/MRN# Appointment: Technologist Clinical Worksheet DOB: Age: Gender: Weight: lbs. Height: Accession# Exam Tech Notes: ****************PREVIOUS EXAM HISTORY*************** Ref Physician: Ref. Phys. Phone: ( Ref Physician Follow Up: Ref. Phys. Fax: Reason for Exam: Signs and Symptoms: How long? History of Trauma: Yes No Surgeries? Tech Notes: Are Outside Studies Available? Yes No Images? Yes No Outside Reports Scanned? Yes No Date of Labs: I-STAT used: Yes No Creatinine mg/dl egfr ml/min CONTRAST ADMINISTRATION Types of Contrast: Oral IV Both Volume/ cc of Lot# Exp. Date Power injector used? Yes No Flow Rate: cc/sec IV INFORMATION Size: g IV Location: R L # of Attempts DC d intact? Yes No Discharge Instructions Given? Yes No Patient Education Given? Yes No Special Instructions:

5 Mammography Patient Questionnaire Date: Your Referring Physician: DOB: Have you had a previous mammogram? When: Where: Are you having any of these problems now with your breasts: New Lump: New Pain: Nipple Discharge: Have you had any of these procedures on your breasts: Needle Biopsy: Right: Left: When: Surgical Biopsy Right: Left: When: Lumpectomy Right: Left: When: Mastectomy Right: Left: When: Reduction Right: Left: When: Implants Right: Left: When: Radiation Right: Left: When: Have you ever had breast cancer? If yes, when: Is there breast cancer in your family? In whom: Sister: Mother: Daughter: Other: Age: Are you pregnant? Date of last period? How many full term pregnancies? Are you taking hormone replacement? When did you start? Please check your menopausal status: Premenopausal: Currently in menopause: Postmenopausal: Have you had a weight change since your last Mammo? No Loss Gain How much: lbs Tech Notes: Tech: Equipment Cleaned: Printed: MRN/Jacket #

6 MRN/Jacket #: MRI Safety Form DOB: Referring Physician: Procedure Accession #: WARNING! The MR system has a very strong magnetic field that may be hazardous to individuals entering the MR environment or MR system room if they have certain metallic, electronic, magnetic, or mechanical implants, devices, or objects. Therefore, all individuals are required to fill out this form BEFORE entering the MR environment or MR system room. Be advised, the MR system magnet is ALWAYS on. Please indicate if you have any of the following: Swan-Ganz or thermodilution catheter Radiation seeds or implants Cardiac Pacemaker Medication Patch (Nicotine, Nitroglycerine) Implanted Cardioverter defibrillator (ICD) Wire mesh implant Aneurysm Clip(s) Surgical staples, clips, or metallic sutures Electronic implant or device Artificial or prosthetic limb Magnetically activated implant or device Joint replacement (hip, knee, etc.) Neurostimulation system Bone/joint pin, screw, nail, wire, plate, etc.) Spinal Cord Stimulator Any metallic fragment, BB, shrapnel or foreign body Internal electrodes or wires Vascular access port, PICC line or catheter Bone growth/bone fusion stimulator Dentures or partial plates Cochlear, otologic, or other ear implant Tattoo or permanent makeup Insulin or other infusion pump Body piercing jewelry Implanted drug infusion device Hearing aid (Remove Hearing aid(s) before entering MR system room) Shunt (spinal or ventricular) Breathing difficulties or motion disorder Tissue expander (e.g. breast) Claustrophobia Any type of prosthesis (eye, penile, etc.) Eyelid spring or wire Metallic stent, filter, or coil Heart valve prosthesis IUD, diaphragm, or pessary ANY Other implant: Please consult the MRI Technologist or Radiologist if you have any question or concern BEFORE you enter the MR system room. Have you experienced any problem related to a previous MRI examination or MR procedure? If yes, please describe: Have you had an injury to the eye or any other body parts involving a metallic object or fragment (e.g. metallic slivers, shavings, foreign body, BB, bullet, shrapnel etc.) If yes, please describe: IMPORTANT INSTRUCTIONS Before entering the MR environment or MR system room, you must remove ALL metallic objects including hearing aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paperclips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, guns, nail clipper, tools, clothing with metal fasteners, & clothing with metallic threads. I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form and regarding the MR procedure that I am about to undergo. If I am to have intravenous contrast with my MRI, I have been informed of the risks of possible allergic reactions and that patients with kidney disease can suffer serious to fatal effects by receiving gadolinium based contrast agents. Signature of Person Completing Form: Date: / / Form Completed By: Patient Relative Nurse: Form Information Reviewed By: Print Name Print Name Relationship to Patient Signature MRI Technologist Translator/ Translator# Radiologist Other