‫المملكة العربية السعودية‬

Kingdom of Saudi Arabia

‫وزارة الصحة‬
Ministry of Health
‫المديرية العامة للشئون الصحية بمنطقة الرياض‬
Directorate General of Health Affairs Riyadh Region
‫مجمع إرادة للصحة النفسية بالرياض‬
Eradah Complex of Mental Health

MRI REQUEST FORM

Patient’s Name : <PATIENT_NAME> Ward/Clinic: <WARD>
Nationality: <NAT> Hospital No:
SEX: <SEX>
Age: <AGE>

*Pls, check for possible hazard: (YES) or (NO)

<CARDIAE_PACE
Pregnancy <PREGNANCY> Cardiae Pacemaker
MAKER>
<INTRACRANIAL
<SURGICAL_CLIP
Surgical Clips Intracranial Vascular Clips _VASCULAR_CLI
S>
PS>
<ARTIFICIAL_HEA
Artificial Heart Valves Intraocular Metallic F .B <I_M_F_B>
RT_VALVES>
Joint Prosthesis , Fixation Material Nail, Plate etc. <J_P>
IF yes, Please specify whether it is MRI Compatible or Not
<PREVIOUS_SUR
Previous surgery (please specify)
GERY >
<ANY_MEDICAL_
IF there is any medical illness (specify)
ILLNESS >
Level of urea: <LEVEL_OF_UREA> &Level of creatinine:
<LEVEL_OF_CREATININE>

Examination Requested: <EXAMINATION_REQUESTED>

Clinical Details and Provisional Diagnosis: <C_D_P_D>

<DIAG>

Treated Consultant Signature/Stamp: <DOC_AUTHOR> Date:

Bleep # <DOCUMENT_LAST_DATE
>
Technologist Name: No. of Films Appointment on:
Date: / /
 ‫المملكة العربية السعودية‬
Kingdom of Saudi Arabia
‫وزارة الصحة‬
Ministry of Health
-This form must be completed by the referring clinician‫الرياض‬
(specialist‫بمنطقة‬ ‫الصحية‬
/ Consultant) ‫للشئون‬
related to his‫المديرية العامة‬
Directorate General of isHealth
specialty who Affairs
responsible Riyadh
for ensuring Region
that the details are correct Failure to comply may result, in the
patient’s safety being compromised.
‫مجمع إرادة للصحة النفسية بالرياض‬
Eradah Complex
-patient to bring allof Mental
related previousHealth
X-Rays and Reports.