Get Lakeside Mri &amp

Completing the LAKESIDE MRI & Diagnostic Center form is a crucial step in receiving medical imaging services. This guide will provide you with clear, step-by-step instructions on how to fill out the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the form effortlessly.

1. Press the ‘Get Form’ button to obtain the necessary form and open it for editing.
2. Begin by entering your personal information in the 'Patient Information' section. Fill in your name (last, first, middle initial), address, sex, date of birth, age, social security number, and marital status.
3. Provide the name of your referring physician and their contact information. Additionally, include your cell phone, home phone, work phone, and email address.
4. In the 'Emergency Contact' section, provide a name and phone number for someone who can be reached in case of an emergency.
5. If the responsible party is different from the patient, fill out their name, relationship, social security number, and date of birth.
6. Indicate whether this visit is a result of a work injury or accident by checking the appropriate boxes, and if yes, provide the date of injury or accident and any relevant claim or attorney information.
7. Read and authorize the 'Medical Release/Authorization' section, where you authorize the release of your medical records and information. This section also requires your signature and date.
8. Acknowledge receipt of privacy policies by signing the privacy acknowledgment and, if applicable, indicating your relationship to the patient if the form is signed by someone other than the patient.
9. Complete the MRI questionnaire by answering all medical history questions accurately, including allergies, previous surgeries, and any prostheses or implants.
10. For female patients, answer questions regarding pregnancy or breastfeeding. Ensure to sign and date the questionnaire, confirming the accuracy of the provided information.
11. Finally, review all the completed sections for accuracy. After confirming that all information is correct, you can save the changes, download, print, or share the form.

Complete your LAKESIDE MRI & Diagnostic Center documents online today for a streamlined experience.