Rowlett-Casa Linda-New V2

Promo Code: ____________
ROWLETT
8405 Lakeview Parkway, Suite 220
Rowlett, Texas 75088
Phone: 972-412-0211 • Fax: 972-412-0799
High Field Open MRI • CT • Ultrasound
CASA LINDA PLAZA
9440 Garland Road, Suite 190
Dallas, TX 75218
Phone: 214-388-2030 • Fax: 214-388-0645
Open MRI
Today’s Date: ____/____/______
Patient Name: ________________________________________________________
DOB: _________________ Employer: ___________________________________ SS#: _____________________
Insurance: _____________________________________
Group #: ________________________________________
Policy #: _______________________________________
Authorization: ____________________________________
Cell Phone: ____________________ Home Phone: _____________________ Work Phone: ____________________
Appointment Date: ____________________
Time: ______________________ Pregnant:
Yes
No
Referring Physician (Print): ______________________________________
________________________
_______________________________________________
__________________________
Diagnosis: ___________________________________________________
STAT REPORT ___________________
Reason for Exam: ______________________________________________
CALL STAT ______________________
Needs Transportation
Deliver CD
Send CD With Patient
Referring Physician Signature: _________________________________________________________________________
MRI
MRA ____________
Brain
Orbits
Pituitary
Soft Tissue Neck
IAC’s
Spine
C T L (circle one)
Abdomen (Rowlett Only)
Attn: _______________
Pelvis
Bilateral Breast (Rowlett Only)
With Contrast
Abdomen Complete
Abdomen Attn: Liver
Abdomen Attn: Gall Bladder
Pelvis & Transvaginal (if needed)
CT (Rowlett Only)
Foot
R L
Ankle
R L
Knee
R L
Hip
R L
Shoulder
R L
Elbow
R L
Wrist
R L
Hand
R L
Other _______________
Without Contrast
Brain
Complete Sinuses
Limited Sinuses
Soft Tissue Neck
Extremity _______________
Chest
Lung Screening
Spine
C T L (circle one)
Abdomen
Pelvis
3D Recon
CTA ________________
Other ________________
With & Without Contrast
Ultrasound (Rowlett Only)
Transvaginal Only
OB-Complete
Testicular/Scrotal
Male Pelvis
Sedation (Valium or Xanax)
Valium Xanax
Drug Name: _____________________________________
RAD to Determine
Renal (Kidneys w/Bladder)
Soft Tissue: __________________________
Other: ______________________________
Strength: ______________
Quantity: __________
Directions: ______________________________________________________________________________________
Physician Signature (Sedation): _______________________________________________________________________
For sedation, a second, manual signature is required (signature stamps not valid).
All Insurance Plans Accepted
www.preferredmri.com
Exam Preparation
Locations
Amarillo
14 Medical Drive
Amarillo, Texas 79106
806-355-5136 Fax: 806-355-5196
High Field Open MRI
Phone:
Casa Linda Plaza:
Phone:
Cedar Hill:
MRI Scan
9440 Garland Rd., Suite 190
Dallas, Texas 75218
214-388-2030 Fax: 214-388-0645
Open MRI
buttons or closures. Patients with pacemakers, aneurysm
clips in the brain, certain ear implants, implanted neurostimulators, metallic fragments in one or both eyes, or other
surgically implanted devices should contact the imaging
center prior to their appointment.
318 W. Beltline Road, Suite 301
Cedar Hill, Texas 75104
972-291-6888 Fax: 972-291-6883
Open MRI, CT, Ultrasound, X-Ray
Phone:
Corinth:
4851 S. Interstate 35E, Suite C-105
Corinth, Texas 76210
940-270-5110 Fax: 940-270-5115
Open MRI
Phone:
Denton:
1614 Scripture St., Suite 2
Denton, Texas 76201
940-387-6159 Fax: 940-387-3468
CT, Ultrasound, Xray
Phone:
Forest Park:
MRI Scan Breast
to exam.
5920 Forest Park Rd., Suite 560
Dallas, Texas 75235
214-350-0708 Fax: 214-350-0712
MRI, CT, Ultrasound
Phone:
Fort Worth
Frisco
4525 Ohio Drive, Suite 200
Frisco, Texas 75035
469-300-2025 Fax: 469-362-5737
High Field Open MRI, CT
Phone:
Grapevine:
1600 W. Northwest Hwy., Suite 1000
Grapevine, Texas 76051
817-416-7545 Fax: 817-416-7301
MRI, CT, Ultrasound, Xray,
Myelograms, Discograms, Arthrograms
Phone:
Hurst:
Abdominal Ultrasound
prior to exam.
809 W. Harwood Road, Suite 100
Hurst, Texas 76054
817-788-5502 Fax: 817-788-5775
Open MRI
Phone:
McKinney:
Patient must be NPO 6 hours
Pelvic/OB Sonogram
Drink at least four glasses
of water one hour before the exam. Do not urinate before
the exam because a full bladder is required.
1717 W. University Blvd., Suite 405
McKinney, Texas 75069
214-544-1118 Fax: 972-548-1445
Open MRI
Phone:
Patient must be NPO 6 hours prior
CT Scan
For scans with contrast, patient must not
eat or drink anything six hours prior to their appointment.
Patients must arrive 45 minutes early for contrast. Any
required blood tests (B.U.N. /Creatinine levels) can be
performed on site at Preferred Imaging.
851 Grainger Street, Suite 101
Fort Worth, Texas 76104
817-659-2870 Fax: 817-885-7912
High Field Open MRI
Phone:
No preparation required.
Medical City Dallas: 7777 Forest Lane, Suite C-112
Dallas, Texas 75230
Phone:
972-566-2900 Fax: 972-566-2930
MRI, CT
X-Ray
No preparation required.
2241 Peggy Lane, Suite F
Garland, Texas 75042
972-521-3100 Fax: 972-276-1761
Open MRI
Peggy Lane:
Phone:
Plano:
2205 N. Central Expressway, Suite 185
Plano, Texas 75075
972-312-0799 Fax: 972-312-8187
Open MRI, CT, Ultrasound, Xray
Phone:
Plano Parkway:
Phone:
Richardson:
5072 W. Plano Parkway, Suite 170
Plano, Texas 75093
972-248-1924 Fax: 972-248-0333
MRI
www.preferredmri.com
1778 North Plano Road, Suite 300
Richardson, Texas 75081
972-234-0004 Fax: 972-234-0035
MRI, CT, Ultrasound, Myelograms,
Discograms, Arthrograms
Phone:
Round Rock:
Phone:
Facebook.com/PreferredMRI
16000 Park Valley Drive, Suite 150
Round Rock, Texas 78681
512-828-3220 Fax: 512-828-3222
Twitter.com/PreferredMRI
MRI, CT, Myelograms, Discograms, Arthrograms
Rowlett:
8405 Lakeview Parkway, Suite 220
Rowlett, Texas 75088
972-412-0211 Fax: 972-412-0799
High Field Open MRI, CT, Ultrasound
Phone:
ARRIVE 15 MINUTES EARLY
190
DALR
OCK
ROAD
ROWLETT ROAD
66
30
Rowlett
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LAKEVIEW PKWY
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LAKE POINTE
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Casa Linda