781 S. Weir Canyon Rd., Suite 185 Anaheim Hills, CA 92808 Phone: 714.282.8160 Fax: 714.282.7031 www.anaheimhillsmri.com Tax ID# 27-3645722 MRI • MRA • ULTRASOUND • X-RAY Date: Phone No. From the office of Dr: Fax No. S.S. No. PATIENT INFORMATION Name: DOB: Home Phone: Work Phone: CIRCLE EXAM REQUESTED MRI MR ARTHROGRAM 9 Routine MR ANGIOGRAM of Diagnosis / Symptoms: X-RAY of Diagnosis / Symptoms: ULTRASOUND of Diagnosis / Symptoms: Referring Physician Signature (required): Previous Study Information: INSURANCE INFORMATION Insurance Company: Ins. Ph. # Insured Name: I.D. # Employer Name or Group # Adjuster: Phone No. Attorney Name: Phone No. Date of Injury: AH-001 (2-15) 9 STAT MAGNETIC RESONANCE IMAGING – MRI You cannot be scanned if you have a pacemaker, intracranial aneurysm clips, transcutaneous nerve stimulators or metal fragments in your body. You may eat and drink as usual on day of exam. Wear comfortable loose fitting clothing (e.g. a jogging suit). If you think you might be claustrophobic, please notify the MRI department prior to your exam. ULTRASOUND EXAM PREPS (May have prescribed medications with small amount of water). Exam 1. Abdomen Gallbladder 2. Pelvis – OB Studies 3. Abdomen & Pelvis (Exams schedule for the same day) Renals (Kidneys) 4. Arterial/Venous (Lower Ext) Arterial/Venous (Upper Ext) Carotid Arteries 5. Aorta Preparation No food or drink 8 hours prior to exam. During 12 hours prior to exam, please exclude all dairy products and fried foods from your diet. (Diabetics may have a small snack equal to 1 cup). One hour before appointment time, start drinking 32 oz. of water. Please have water completed 30 minutes prior to appointment time. DO NOT EMPTY BLADDER. You may eat normally. No food or drink 8 hours prior to exam. One hour before appointment time, starting drinking 32 oz. of water, please have water completed 30 minutes prior to appointment time. DO NOT EMPTY BLADDER. (Diabetics may have a small snack equal to 1 cup). NO PREP No food or drink 8 hours prior to exam Anaheim Hills Imaging Center is located in the Chase / Ralphs Grocery Store shopping center on the corner of Weir Canyon Rd and Serrano Ave. Driving Directions: Traveling eastbound on the 91 Fwy: Exit Weir Canyon Rd and turn right (south). Continue on Weir Canyon Rd. After you pass Monte Vista Rd, you will make a right into the shopping center closest to the Mobile K gasoline station. As you enter into the parking lot, make a left after the first stop. 781 S. Weir Canyon Rd., Suite 185 Anaheim Hills, CA 92808 Phone: 714.282.8160 • Fax: 714.282.7031 www.anaheimhillsmri.com Tax ID# 27-3645722 Traveling westbound on the 91 Fwy: Exit Weir Canyon Rd and turn left (south). Continue underneath the 91 Fwy overpass. You will continue on Weir Canyon Rd. After you pass Monte Vista Rd, you will make a right into the shopping center closest to the Mobile K gasoline station. As you enter into the parking lot, make a left after the first stop.