to - Anaheim Hills Imaging Center

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.