MRI Form

Please fill the form completely. All fields are required.

If you haven't already done so, please don't forget to accomplish the Release Form. Click on the link below to open the form in another window.

Patient Release Form

Gender *

Are you pregnant, or suspect you may be pregnant?

I am pregnant

I use an IUD

I am breastfeeding

I am postmenopausal

I have had a hysterectomy

Have you had any surgery related to this area? *

Have you had other surgeries? *

Have you had an injury by a metallic object to the eye or foreign body? (e.g., metallic slivers, BB, bullet, etc.) *

Are you currently taking or have you recently taken any medication or drug? *

Are you allergic to any medication? *

Do you have or have you had any of the following: *
Please list any other medical conditions not listed above:

Your referring physician has ordered MRI contrast enhancement to obtain more diagnostic information of the brain, chest, neck, abdomen, pelvis or other area of your body. IV insertion is necessary to inject IV contrast into the vein to better enhance the soft tissue and blood vessels. In very rare cases some patients have been known to have an allergic reaction to the IV contrast (medications are on hand to treat these conditions should they occur). In some very rare cases of those patients having reaction, death may occur. The MRI technologist or paramedic will be happy to answer any questions you may have about this test.

Please indicate if you have any of the following: *

I attest that the above information is correct and to the best of my knowledge. I read and understand the contents of this form and had the opportunity to ask questions regarding the MR examination.

Patient Information Consent Form

Please initial lines 1-5

It is understood that the diagnostic procedure(s) ordered by my physician will be performed by Global Imaging and do hereby authorize and consent to such service.


I hereby authorize Global Imaging to release any medical information regarding the services performed to my personal physician, insurance company, and or employer (in the event of a worker’s compensation injury).


A quote of benefits and/or authorization does not guarantee payment from your insurance companies. It is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. The undersigned hereby agrees to pay all charges not covered by the health nsurance company. Any balance not paid within 90 days after the date of service will be considered in default unless financial arrangements have been made with the business office.


I acknowledge I have read and agree with the HIPAA policy. If for any reason I am unable to pick up my personal records, I understand Global Imaging office policy requires proof of family/friend identity to release my information.

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or otherwise as permitted by such regulations.



I consent to receive text messages and emails from Global Imaging, LLP. I understand that this request to receive emails and text messages will apply to all future appointment reminders and updates.

I, the undersigned, have read the above and authorize the staff of Global Imaging to disclose such information as herein contained.