How to get radiology image on kaiser: Fill out & sign online

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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 'Yes', provide details about when and where it occurred.
Answer questions regarding personal history of cancer, medications taken today, previous procedures/surgeries, and any past procedures involving your brain. Be thorough in your responses.
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 or a responsible party signs and dates the form at the bottom before submission.

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