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Schaefer Rd. Roemer Charles Lapham Basha Diagnostics Medical Records Administrative Office Dearborn Clinic 4407 Roemer Dearborn MI 48126 313 584-0769 Fax 313 945-9339 Greenfield Rd. Basha Diagnostics P. C. Open MRI available ROYAL OAK MED. CLINIC STERLING HEIGHTS CLINIC DEARBORN ROEMER CLINIC MEDICAL RECORDS/ADMINISTRATION 248 435-8066 586 566-8680 313 584-0768 FAX 313 945-9339 248 288-1600 FAX 248 288-2171 Open MRI MRI/MRA Imaging Center MRI APPOINTMENT IN 24-48 HOURS www. BashaDiagnostics. com Please contact the Royal Oak 13 Mile Clinic for ALL MRI Scheduling. 4045 W* 13 Mile Rd. Royal Oak MI 48073 Phone 248 435-8066 Fax 248 435-8099 Patient Information Date Patient s Name Sex M F Age Claustrophobic Y N Referring Physician Information Name Phone No* Address City Please Notify Basha Diagnostics Staff if the patient needs transportation* 248 435-8066 Each patient will receive a complimentary CD of their study - upon request. Appointment Date MRI Appointment Time Head Chest Complete Spine Pelvic and Abdominal Upper and Lower Extremities. Other Head Abdomen Brain MRI Contrast Circle Attention To IAC s Sinuses Pituitary Carotids MRA Orbits Neck - Soft Tissue Thyroid Palpable Mass Liver / Spleen Kidneys Pancreas Gallbladder / Biliary Adrenal Entire MRA MRV Extremities Shoulder Hip Knee Ankle Foot Elbow Wrist Hand L R TMJ L R Contrast Enhanced MRA Spine Complete Cervical Thoracic Lumbar Sacral Renal Arteries Aorta Lower Extremities MRV-Lower Extremities Other Pelvis Brachial Plexus Specify MUST BE COMPLETED BY ORDERING PHYSICIAN Rule out Diagnosis Clinical Information REQUIRED BY BLUE SHIELD OF MI FOR ALL B/S PATIENTS Physician s Signature Form 202 oo W I-75 ks 14 Mile Schoenherr M-53 Croo Southfield Romeo Plank BASHA DIAGNOSTICS P. C. MRI LOCATIONS M-59 dw ar Garfield ld Hayes ica Ut fie Green Coolidge Van Dyke d Ca ss I-696 Royal Oak Clinic Sterling Heights Clinic 13753 19 Mile Rd. Southfield Fwy. M-39 Michigan Ave. Pontiac GM Buick Dealer Ford Rd. 30701 Woodward Avenue Suite LL 248 288-1600 FAX 248 288-2171 FOR BILLING AND INSURANCE INQUIRIES CONTACT. BashaDiagnostics. com Please contact the Royal Oak 13 Mile Clinic for ALL MRI Scheduling. 4045 W* 13 Mile Rd. Royal Oak MI 48073 Phone 248 435-8066 Fax 248 435-8099 Patient Information Date Patient s Name Sex M F Age Claustrophobic Y N Referring Physician Information Name Phone No* Address City Please Notify Basha Diagnostics Staff if the patient needs transportation* 248 435-8066 Each patient will receive a complimentary CD of their study - upon request. Royal Oak MI 48073 Phone 248 435-8066 Fax 248 435-8099 Patient Information Date Patient s Name Sex M F Age Claustrophobic Y N Referring Physician Information Name Phone No* Address City Please Notify Basha Diagnostics Staff if the patient needs transportation* 248 435-8066 Each patient will receive a complimentary CD of their study - upon request. Appointment Date MRI Appointment Time Head Chest Complete Spine Pelvic and Abdominal Upper and Lower Extremities.

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