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Contact Us

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PATIENT INFORMATION

Choose the location

Patient name

First

Last

Date Of Birth*

Phone*

Height*

Interpreter (Language)

Weight*

Pregnant?

Yes

No

Allergies

Claim Numbers*

Attorney

Date of Injury*

Attorney Phone

Insurance Name

3rd Party

PIP

ICD-10 Code*

CLINICAL HISTORY (REQUIRED)

Symptoms*

Duration*

Area Of Body*

Cause (Hx,Trauma,etc.)*

Is this due to injury?

Yes

No

If yes, Specify

MVA

Other

MRI EXAM

Exam priority*

Routine

Urgent

MRI Exam

Patient may have metal in eye (Perform X-ray for determination of foreign body if needed)

Patient has pacemaker

Patient has implanted device:

Implanted device

Provider name*

Clinic*

Phone*

Date*

Email address*

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Get In Touch

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Reach Out To Us

Phone: 425-386-3607

Fax: 425-386-3608

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Email Address

KarenP@CoastMRI.com

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PACS Portal

Link: www.omegaai.com

PROVIDER PORTAL