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Forms
Online Registration Form
Patient Information
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Indicates required field
First Name
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Middle Name or Initial
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Last Name
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Street Address
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City
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State
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Zip
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Date of Birth
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Phone Number
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Email
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Insurance Information
Primary Insurance
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Primary ID
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Secondary Insurance
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Secondary ID
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Attach a copy (photo or pdf) of the front of your Picture ID and the front of each Insurance Card
Picture ID
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Max file size: 20MB
Primary Insurance Card
*
Max file size: 20MB
Secondary Insurance Card
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Max file size: 20MB
I am aware that IF my referring doctor has requested a copy of my images, I will be given one.
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Agree
Disagree
I am aware that I can notify ADI that I would like to purchase additional imaging copies at $10 per CD
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Agree
Disagree
I would like an emergency contact to be listed:
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Agree
Disagree
Emergency Contact Name
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Emergency Contact Cell
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I am aware there may be an estimated patient financial responsibility, and if so, I agree to pay at time of service by:
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Credit Card
Check
Cash
I attest that all above information listed above is correct and/or I have notified front desk of correction.
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Agree
Disagree
My printed name before gives consent for the MRI today.
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Agree
Disagree
Complete Patient Name
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Date
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For Office Use Only
CPT Code 1
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Date of Service 1
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Diagnosis/Description 1
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Tech Initials 1
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CPT Code 2
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Date of Service 2
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Diagnosis/Description 2
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Tech Initials 2
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CPT Code 3
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Date of Service 3
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Diagnosis/Description 3
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Tech Initials 3
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CPT Code 4
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Date of Service 4
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Diagnosis/Description 4
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Tech Initials 4
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CD Given to Patient at TOS
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CD Checked by Tech
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CD Checked by Front Desk
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Estimated Patient Responsibility
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Physician
*
Physician Phone
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Physician Fax
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Chart #
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Pt Appt
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Submit
New Patient Form
*
Indicates required field
First Name
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Middle Name or Initial
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Last Name
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Email
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Phone Number
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Birthdate (xx/xx/xxxx)
*
***The below items may interfere with Magnetic Resonance Imaging (MRI) and some could be potentially dangerous.***
Therefore, please indicate if you have any of the following and the MRI technologist will review this form with you verbally after completion.
Please discuss in detail with the tech any of the below listed as "Yes."
Please answer "No" or "Yes" for each of the following. If you answer "Yes," please provide details.
Pacemaker (If Yes, you cannot have MRI)
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No
Yes
Pacemaker Details
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Heart Surgery (bypass, stent, valve)
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No
Yes
Heart Surgery Details
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Brain Surgery or Aneurysm Clips
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No
Yes
Brain/Aneurysm Details
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Ear Surgery/Cochlear Implant/Heading Aids
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No
Yes
Ear Details
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Eye Surgery or Lens Implant
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No
Yes
Eye Details
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Pins, Screws, Plates Implanted
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No
Yes
Pins Details
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Joint Replacement/Prosthetic Device
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No
Yes
Joint Details
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Mechanical Devices (pain, pump, stimulator)
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No
Yes
Mechanical Details
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Any Other Implanted Items
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No
Yes
Other Implanted Details
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Bullets, Pellets, Shrapnel
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No
Yes
Bullets Details
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Have you been out of the U.S. in the last 2 weeks?
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No
Yes
Out of U.S. Details
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Have you been sick with a fever in the last 3 days?
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No
Yes
Fever Details
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Are you pregnant or nursing?
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No
Yes
Pregnant Details
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Do you have Tattoo or Tattoo makeup?
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No
Yes
Tattoo Details
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Please describe below your symptoms, pain, and/or problems associated with the MRI:
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How long have you experienced symptoms?
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If you were injured, what was the date?
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If you were injured, how did it occur?
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Lifting
Falling
Sports
Work Related
Car Accident
Other location of injury
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Have you ever had cancer?
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No
Yes
Date of Cancer
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Type or body area of cancer
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Have you had surgery on the area we are performing the MRI?
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No
Yes
If surgery, then give date and type.
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What is your height (required for MRI machine)?
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What is your weight (required for MRI machine)?
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If you have a follow up with your doctor for these MRI results in the next 2 days, please verbally notify the front desk and MRI technologist and give date and time here.
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By printing my name below, I certify that I have described my symptoms and medical history correctly to the best of my ability, and my printed name below authorizes my consent for the MRI.
Type Full Name in Lieu of Signature
*
Date Signed
*
Submit
Consent Form
Magnetic Resonance Imaging (MRI) is one of the most advanced and informative diagnostic procedures. MRI is a method of obtaining images of structures inside of your body by utilizing a large magnet and radio waves, but does not involve any radiation. At American Dynamic Imaging (ADI), we have the Fonar Upright MRI machine which is a .6 Tesla strength.
MRI AWARENESS AND CONSENT:
I am aware that MRI uses a strong magnetic field and can damage Cell Phone, Credit Cards, Watches, and Hearing aids.
I am aware that American Dynamic Imaging (ADI) will provide a locked area for me to place my belongings.
I am aware that I am required to notify technologist on duty if I am pregnant or if I have metallic devices or implants.
I am aware that my referring doctor will receive a copy of my medical records and it is typically their wish to go over these records with me at my next appointment.
I am aware that my medical records are available from ADI for seven years.
I consent that I have described my symptoms and medical history to the best of my ability.
MY AUTHORIZATION WITH THE ADI FACILITY INCLUDES:
My authorization for treatment at the ADI facility.
My authorization to release medical information including reports, images, etc. to my referring doctor, any medical specialist I visit and/or my insurance company.
My authorization to release medical information to the person listed here, if directed:
Name of Person for Release of My Medical Information
*
My authorization for payment of medical benefits to be paid directly to the ADI facility.
My authorization for referring doctors to release medical information to ADI facility.
My authorization for other providers of care to release information which is relative to my MRI today, such as labs, previous images, studies, or reports to ADI facility.
My authorization to be contacted by text or email in regards to future scheduling, billing, and/or other communication.
MY AGREEMENT WITH THE ADI FACILITY INCLUDES:
My signature below confirms that I am 18 years or older and able to give medical consent for myself or I am the legal guardian for the patient.
My understanding that I may be billed for any amounts not covered by my insurance company.
My understanding that I will receive a statement for services rendered and payment is due upon receipt.
My understanding that I will not receive a refund for MI scans completed with diagnostic radiologist report for any purposes except for overpayment due to insurance.
ADI will contact my doctor regarding my referral to the facility.
ADI will contact my insurance company regarding my referral to the facility.
ADI will exhaust all valid insurance avenues prior to billing me.
ADI will respect my privacy with normal industry standards.
ADI will provide me a copy of their HIPAA practices if I so request.
ADI will forward the results of my MRI to the referring doctor and/or requesting specialists.
By signing below, I certify that I have read and agree to the above awareness, consent, and authorization and give consent for American Dynamic Imaging to perform the requested MRI.
*
Indicates required field
Type Full Name in Lieu of Signature
*
Date Signed
*
Email
*
Phone Number
*
Name of Patient Representative, if applicable
*
Submit
Home
Patients
Request an Appointment
>
Hurst, Texas
San Antonio, Texas
New Patient Form
Insurance
Patient Satisfaction
Testimonials
Submit a Testimonial
Physicians
Positional Imaging
Referral Forms
Spine Journal Study
Case Studies
FAQ's
About Us
Locations
>
Hurst, Texas
San Antonio, Texas
Technology
>
Benefits
Position Imaging
Specifications
Privacy Policy
Contact Us
>
Hurst, Texas
San Antonio, Texas
Blog