PATIENT INFORMATION: CONTACT INFORMATION: EMERGENCY CONTACT: EMERGENCY PHONE: RESPONSIBLE PARTY (IF OTHER THAN PATIENT)

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PATIENT REGISTRATION PATIENT INFORMATION: NAME:,, (M.I.) ADDRESS:,, (Street) (City) (State) (Zip) SEX: MALE FEMALE DOB: / / AGE: MARITAL STATUS: SS #: / / REFERRING PHYSICIAN: CONTACT INFORMATION: (CELL): - - (HOME): - - (WORK): - - EMAIL: EMERGENCY CONTACT: EMERGENCY PHONE: RESPONSIBLE PARTY (IF OTHER THAN PATIENT) NAME:, RELATIONSHIP: SS#: - - DOB: / / WORK INJURY/ACCIDENT IS THIS VISIT A RESULT OF A WORK INJURY? IF YES, THEN: DATE INJURED: / / INDUSTRIAL CLAIM #: IS THIS VISIT A RESULT OF AN ACCIDENT? IF YES, THEN: DATE OF ACCIDENT: / / ATTORNEY: TEL #: - - MEDICAL RELEASE/AUTHORIZATION I,, authorize Lakeside MRI & Diagnostic Center and its medical and technical staff to perform the necessary diagnostic and treatment procedures requested by my referring doctor. I also give my authorization to Lakeside MRI & Diagnostic Center to release any part or all of my medical records and general information obtained during my visit to this center to any insurance organization, my attorney and other medical personnel involved in my care or any other agency that may require my information. I further understand that this information is stored in an electronic medical records format and may be transmitted to my physician or authorized personnel only after proper identification and authentication. I authorize the release of any medical or other information necessary to process insurance claims on my behalf. I authorize that the payment be made directly on my behalf to LAKESIDE MRI &. I understand that I am responsible for my account whether my insurance covers it or not. I understand that all co- payments, co-insurance, and deductibles are my responsibility and I agree to make full payment upon receiving the balance of my medical bill from Lakeside Open MRI & Diagnostic Center. I also authorize Lakeside MRI & Diagnostic Center to release this signature to the Social Security Administration (Medicare) and other government agencies, Workers Compensation, or billing agents. Referring physician authorizes Lakeside MRI & Diagnostic Center to contact patient's managed care plan or other insurer on behalf of Referring Physician to pre-certify the patient for the procedure being requested and to provide scheduling services for the patient being referred.

PATIENT PRIVACY ACKNOWLEDGEMENT PRIVACY POLICIES ACKNOWLEDGEMENT RECEIPT: Name:, Use and disclosure of protected health information is regulated by a federal law known as The health Insurance Portability and Accountability Act of 1996 (HIPAA). Under HIPAA, providers of healthcare are required to give patients an opportunity to review and/or obtain a copy of their Notice of Privacy Practices for Protected Health Information and make a good faith effort to obtain a written acknowledgment that this notice was received. I have been presented with a copy of LAKESIDE MRI & S Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. : / / If signed by someone other than the patient, please indicate relationship to patient: Name:, Relationship: OPTIONAL I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information: X (Please Initial) INTERNAL USE ONLY: If the patient or patient's representative refuses to sign this acknowledgement of receipt of notice, please document the date the notice was presented to the patient and sign below: DATE PRESENTED: / / LAKESIDE REPRESENTATIVE: FAX PRIVACY WAIVER I understand that my medical records may be transmitted electronically by fax and may be received in error by a third party. In the event that this should occur, I absolve Lakeside MRI & Diagnostic Center of all liability. I give my consent to fax my records for the purposes of treatment, payment, or healthcare options, and I understand that I may withdraw this consent in writing at any time. of patient or representative Printed name of patient or representative

MRI QUESTIONNAIRE NAME:,, (M.I.) MEDICAL HISTORY ARE YOU EXPERIENCING PAIN OR OTHER SYMPTOMS? If yes, please list: ARE YOU BEING TREATED FOR ANY OTHER MEDICAL PROBLEM? If yes, please list: HAVE YOU EVER BEEN DIAGNOSED WITH CANCER? If yes, please describe: HAVE YOU EXPERIENCED TRAUMA OR INJURY RECENTLY? If yes, please describe: HAVE YOU HAD ANY SURGERY? If yes, please list: DATE: DATE: DATE: _ ARE YOU ALLERGIC TO: MEDICATIONS? If yes, please list: IODINE? SHELLFISH? OTHER? ARE YOU DIABETIC? If yes, please list: If yes, please list: If yes, please list: If yes, what medication(s) are you currently taking for this condition? DO YOU HAVE HYPERTENSION? DO YOU HAVE HISTORY OF RENAL FAILURE OR KIDNEY DISEASE? DIALYSIS? HAVE YOU EVER HAD A PREVIOUS REACTION TO ANY CONTRAST MEDIA? HAVE YOU HAD ANY OTHER DIAGNOSTIC TESTS FOR THIS CONDITION? WHERE?WHEN? WHAT KIND? FEMALE PATIENTS ONLY ANY CHANCE OF PREGNANCY? ARE YOU CURRENTLY BREASTFEEDING? I attest that the above information is correct to the best of my knowledge. I have read and understand the entire contents of this form and I have had the opportunity to ask questions regarding this information.

NAME:, PLEASE INDICATE IF YOU HAVE THE FOLLOWING: YES NO If yes, please explain: Cardiac Pacemaker? Aneurysm clip (metal clips put around blood vessels during surgery)? Electrical Stimulator for nerves, bone or brain? Ear or Eye implants (e.g. cochlear implants or hearing aid)? Implanted insulin, drug or infusion pump? Coil, stent, catheter or filter in any blood vessel? Internal electrodes or wires? IUD or diaphragm? Orthopedic hardware, e.g. artificial joints, metal plates, screws, or surgical staples, clips or metal sutures? Any other type of prosthesis or implant? Gun pellets, shrapnel, bullets or metal fragments? Have you had an MRI scan before? Are you claustrophobic? Have panic attacks? Have you ever been a welder, machinist, grinder or worked with metal without eye protection Do you have any tattoos, tattooed eye/lip liner or body piercings? Do you wear dentures, a dental plate or braces (not fillings) Do you have any trans-dermal medication skin patches? Breathing problems or motion disorder? Hearing aid (remove before entering MR room) FEMALE PATIENTS ONLY ANY CHANCE OF PREGNANCY? ARE YOU CURRENTLY BREASTFEEDING? I have read and understand the questions in this questionnaire and that the above responses are correct to the best of my knowledge. I understand that it is my responsibility to inform the Center of any metal fragments and/or devices that may be in my body and that by failing to do so may cause serious bodily injury or be life threatening. I agree that should I have any metal in my body, and after consultations with my physician, elect to proceed with the MRI, I agree to release the Center from any and all liability for any injury. DO NOT BRING ANYTHING INTO THE SCAN ROOM WITH YOU. Please remove all metal objects including keys, hair pins, barrettes, jewelry, watches, safety pins, paperclips, money clip, credit cards, coins, pens, belt, metal buttons, pocket knife, cell phone, & clothing with metal in the material. TECH INITIALS:

MRI PREGNANCY RELEASE FORM NAME:, Thank you for coming to our facility and allowing us the opportunity to serve you. We sometimes ask for the cooperation of our patients by asking "personal" but necessary and important questions in order to provide you quality care. 1. Are you pregnant or do you think you may be? NO YES 2. Have you recently had a pregnancy test? NO YES If yes, test date: / / Negative Positive Dr. 3. of last menstrual period: / / Post Menopausal? NO YES 4. Are you taking oral contraceptives or receiving hormonal treatment? NO YES 5. Are you currently breastfeeding? NO YES This exam uses magnetic fields and radio waves to image the body. There are no known harmful effects on the developing fetus or mother, however, long term experience is lacking. An MRI exam WILL NOT be performed during the first trimester of pregnancy. I understand there could be unknown risks to the fetus but by signing this form, I am agreeing to this test. TECHNOLOGIST COMMENTS: TECHNOLOGIST INITIALS:

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