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Sat - 8:00 AM - 6:00 PM

Call for an appointment:
770-953-0108









Medica Stand-Up MRI of Atlanta
6590 Powers Ferry Road
Atlanta, GA 30339

Phone: 770-953-0108
Fax: 770-953-0109

Click here for directions.



 

Referral Form



Prefer to email, fax or mail your order form in? Please click here to download a PDF of our referral form.
* = Required Fields
General Information
*Date Ordered:
Appointment Date/Time:
*Patient Name:
DOB:
Home Phone Number:
Work Phone Number:
*Referring Physician Signature:
*Office Phone Number:
*Office Fax Number:


Procedure Ordered
Brain:
MRA:
Body Imaging:
(Recumbent Only)
Lower Joints: (no arthrograms)
Upper Joints: (no arthrograms)
Cervical:
Thoracic:
Lumbosacral:
Exam Is:
Radiologist's Discretion:


Patient History
Does patient have or ever had a pacemaker?
Does patient have any ear or eye implants?
Is the patient pregnant?
Previous Surgery to the Area Being Scanned?
Body Piercing?
Metal In Body?
Brain Aneurysm Clip?
Allergies?




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