Mitchell Mcdonald

 
 MAGNOLIA DIAGNOSTICS, INC. 
 MEDICAL EVALUATION for M.R.I./ CONSENT FOR TREATMENT 
 PATIENT NAME Amy Rodriguez 
 WT. 176 
 SOCIAL SECURITY # 
 HT. 
 DOCTOR'S NAME 
 DAVIS 
 CIRCLE 
 YES 
 NO 
 Have you had an MRI scan before today? 
 Yes 
 No 
 Where? 
 When? 
 Have you ever had surgery of any type? 
 Yes 
 No 
 List: 
 Do you have any metal in your body? 
 Yes 
 No 
 Explain: 
 Do you have a pacemaker, or any device implanted in you? 
 Yes 
 No 
 
 FEMALES ONLY: 
 Are you pregnant or is there a possibility you could be pregnant? Yes 
 No 
 The above questions have been answered truthfully to the best of my 
 knowledge. 
 I 
 do hereby consent to necessary examination procedures and/or 
 treatment by Magnolia Diagnostics, Inc. as prescribed by my treating 
 physician. 
 Signed Amy Rodriguez 
 Date 
 13 July 2017
 Date you are scheduled to return to your Doctor: 
 
