Get Duke University Health System Cardiac Mri Request Form 2017-2025

Filling out the Duke University Health System Cardiac MRI Request Form online is a straightforward process that ensures a smooth request for necessary imaging studies. This guide provides clear, step-by-step instructions to help you navigate the form with ease.

Follow the steps to complete your request form accurately

1. Press the ‘Get Form’ button to acquire the Cardiac MRI Request Form and open it in your preferred editor.
2. Begin by entering the date of the request in the designated field. This date indicates when the request is submitted.
3. Fill in the patient's information, including their name, medical record number (MRN), phone number, and date of birth.
4. Provide the name of the ordering physician, along with the information regarding where the report should be sent. Include the box and fax number, as well as a contact name and phone number.
5. Select the type of study desired by marking the appropriate box(es). Note that if blood flow quantification is indicated, it must be ordered additionally.
6. Include any necessary clinical indications for the exam, making sure to provide relevant ICD-10 codes.
7. Answer questions regarding the patient's medical history, including history of metal in the body, the need for light sedation, pregnancy or breastfeeding status, weight, and renal disease.
8. Obtain the physician's signature in the designated area, ensuring that additional clinical notes and creatinine results are attached.
9. Review the completed form for accuracy. Save any changes made, and choose to download, print, or share the form as required.

Complete your Duke University Health System Cardiac MRI Request Form online today for a seamless submission process.