Requisition Form

(PDF 1MB)

 
Image One MRI
is not affiliated with
Karl Storz Imaging, Inc.
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Image One MRI Booking Procedure

1. The physician completes a requisition specifying the body part(s) to be scanned including all pertinent medical history.  This is preferably done with the patient present to determine whether or not the patient can safely have an MRI study. Absolute contraindications include:

  • Cardiac pacemakers
  • Cochlear implants (non-MR Conditional) 
  • Intracranial aneurysm clips
  • Neurostimulators
  • Programmable hydrocephalus shunts 
  • Weight exceeding 350lbs

**If your patient has had any relevant previous imaging (MRI, CT, US, NM, X-ray), please indicate on the requisition and forward any available report(s).  In some cases Image One MRI may need to obtain previous imaging studies for comparison purposes.     

2. MRI clinic should be consulted if the patient has any of the following:

  • History of metal fragments in eye*
  • Insulin or medication pumps
  • Vascular stents, coils or filters
  • Gunshot wounds

* Patients who have had previous injuries to their eyes with metallic fragments and/or who are unsure as to whether or not any fragments exist must have an orbit x-ray completed to rule out any metallic foreign bodies and the report sent to our clinic before the MRI exam.

Note: We do not scan patients under the age of 16 who require a contrast agent.

3. Fax the requisition to Image One MRI.

4. Upon receipt of the fax, we will contact the patient to:

  • Screen for contraindications
  • Book the appointment
  • Explain MRI process

5. The scan is performed.

6. A CD copy of the exam will be given to the patient.

7. The Radiologist's report will be faxed to the referring physician within two business days after the appointment. The Radiologist does not discuss the findings with the patient.

Third party payers will need to provide a release of information form signed by patient to receive a copy of reports.

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