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Kaiser permanente radiology imaging request form 2026
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- Click ‘Get Form’ to open the kaiser permanente radiology imaging request form in the editor.
- Begin by entering your Name, MRN #, and Date at the top of the form. This information is essential for identifying your records.
- Fill out the MRI Screening Questionnaire. Provide your Weight and Height, and clearly explain the reason for this MRI scan/procedure in the designated space.
- Indicate whether you have had a previous exam related to this problem by selecting 'Yes' or 'No'. If applicable, provide details about when and where it occurred.
- Answer questions regarding personal history of cancer, medications taken today for anxiety, previous procedures/surgeries, and any past experiences with contrast dye.
- Complete the MRI Hazard Checklist by answering each question truthfully. If any questions are answered 'YES', follow the instructions provided regarding consultation with a Radiologist.
- Finally, ensure that you sign and date the form at the bottom to verify that all information is accurate before submission.
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| 2003 | 4.5 Satisfied (58 Votes) |
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