Community Radiology of Virginia

Patient Screening Form

Please fill out this form before your visit.

Patient's First Name

Patients Last Name

Email

Phone

I consent to being contacted via Text Messaging (SMS).

Address

Date of Birth

Month

Day

Year

Sex

Male

Female

Please list if there are any prior MRI, X-ray, CT, or other form of imaging that can help provide information for your evaluation. Indicate the dates and locations where you imaging occured.

Please check Yes or No to all of the following:

If cancer, what type?

Please select either Yes or No if you have any of the following:

These will not prevent you from having an MRI procedure, but it is important for us to know this information.

Have you had a Spinal Fusion procedure?

Yes

No

If Yes, how long ago did you have your fusion procedure?

Have you had a Spinal Fusion device?

Yes

No

How long have you had your fusion device?

Do you have an artificial limb?

Yes

No

What type/where is your artificial limb?

Have you ever had a reaction with Contrast?

Yes

No

If you've had a reaction to contrast, please describe:

Metal Implants

Yes

No

If you have any implants, where in the body:

Please enter your full legal name as your signature:

I agree that entering my name above represents my consent to the submission of the infomation above.