A leading provider of comprehensive whole body MRI services.

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E-Referral Questionnaire

Patient Information

Patient First Name(Required)

Patient Last Name(Required)

Home Phone

Cell Phone

OHIP#

Version Code

Sex

DOB(Required)

MM slash DD slash YYYY

The patient has confirmed

The patient has confirmed that this Whole Body MRI scan is being performed strictly for screening purposes and not to evaluate a known medical condition or symptomatic issue.

Study to Be Performed

Whole Body MRI Screening Examination

Whole Body MRI Scan

Prostate MRI Screening

Liver Fat Quantification MRI

Coronary (Cardiac) CTA with Calcium Scoring

Cardiac Calcium Scoring

Breast MRI Screening

Breast Implant MRI

CT Lung Cancer Screening

List All Surgery

Please list all surgery and specify a date and type:

Date and type

Date of last menstrual cycle

Date

MM slash DD slash YYYY

Height & Weight

Height (ft)

Weight (lbs)

For MRI Patients

Yes No

Have you had a previous MRI?

Yes

No

Has metal ever gone into your eye?

Yes

No

Are you claustrophobic?

Yes

No

Do You Have Any of The Following:

Yes No

Aneurysm Clips

Yes

No

Artificial Cardiac Valve

Yes

No

Cardiac Pacemaker

Yes

No

Cochlear Implants

Yes

No

Coil/Stents

Yes

No

Neurostimulator

Yes

No

Retained Pacing Wires

Yes

No

Shrapnel/Bullets

Yes

No

Other implanted devices,

If YES to any, please specify (date, type, implant model):

Past Medical History:

Active Medical Issues:

Current Medications:

Pertinent Family Medical History:

Allergies

Yes

No

If Yes, please specify allergy and reaction

For CT Patients (Coronary CTA): Previous reaction to IV contrast

Yes

No

Tobacco Use

Yes

No

Packs / Day

Alcohol Use

Yes

No

Drink / Week

Recreational Drugs

Yes

No

If Yes, please specify

Occupation

Do You Exercise Regularly

Yes

No

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855-910-2639

416-572-8704

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This Whole Body MRI scan is intended strictly for screening purposes and not to evaluate a known medical condition or a symptomatic issue.

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