Christopher Paul

 
 MRI SCREENING FORM 
 Patient 
 Name: Christopher Paul 
 SERVICE DATE 
 2016-08-04 
 Pt. ID# 
 C15838046 
 Clinic: 
 Slidell 
 Ht: 5'7 Wt: 250 
 Kevin Rogers: Cell-504-458-8871, Fax-50 -399-8123 Email: kevin.rogers@disnola.com 
 Section 1: 
 1- Do you have a Pacemaker or Defibrillator If yes, complete the implant form and obtain 
 no 
 clearance prior to scheduling. 
 Section 2: 
 Female: Are you pregnant? If yes, obtain trimester information and approval prior to 
 scheduling. 
 Males: Prostate studies only: 
 Any previous prostate MRI? If yes, date and where? 
 Any previous biopsy or PSA? If yes, please acquire? 
 MRI CAN BE SCHEDULED 6-8 WEEKS POST OP SURGERY. 
 Revised: 2015-05-05
