PATIENT INFORMATION

Choose the location

Please selectTUKWILA - 975 Industry Dr, Tukwila, WA, 98188PUYALLUP - 1519 3rd St SE, Suite 103 Puyallup, WA, 98372LYNNWOOD - 18730 33rd Ave W, Suite 100 Lynnwood, WA, 98037

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

Brain (ONLY TUKWILA)

Routine Brain MRI Series

Advanced Brain MRI Series

C-Spine

Routine C-Spine (ALL LOCATIONS)

Add Alar Ligament Protocol (ONLY TUKWILA)

T-Spine

L-Spine

Pelvis

Ankle

Elbow

Knee

Shoulder

Wrist

Hip

With Arthrogram?

Ankle (Left / Right)

L

R

Elbow (Left / Right)

L

R

Knee (Left / Right)

L

R

Shoulder (Left / Right)

L

R

Wrist (Left / Right)

L

R

Hip

L

R

Other

Provider name*

Clinic*

Phone*

Date*

Email address*

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