Scribd Logo
Upload

Welcome to Scribd!

  • Mri Request Form

    Uploaded by

    raad_alghamdi_1
    9 views1 page
    This document is an MRI request form from the Eradh Complex of Mental Health in Riyadh, Saudi Arabia. It requests the patient's name, nationality, sex, age, and any potential hazards like pregnancy, implants, or previous surgery. It asks for clinical details and provisional diagnosis. The treating consultant must sign with their bleep number and date. The technologist will provide the number of films and appointment date. The form aims to ensure patient safety by collecting necessary medical information before the MRI scan.

    Original Description:

    Original Title

    Mri Request Form (1)

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is an MRI request form from the Eradh Complex of Mental Health in Riyadh, Saudi Arabia. It requests the patient's name, nationality, sex, age, and any potential hazards like pregnancy, implants, or previous surgery. It asks for clinical details and provisional diagnosis. The treating consultant must sign with their bleep number and date. The technologist will provide the number of films and appointment date. The form aims to ensure patient safety by collecting necessary medical information before the MRI scan.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    9 views1 page

    Mri Request Form

    Uploaded by

    raad_alghamdi_1
    This document is an MRI request form from the Eradh Complex of Mental Health in Riyadh, Saudi Arabia. It requests the patient's name, nationality, sex, age, and any potential hazards like pregnancy, implants, or previous surgery. It asks for clinical details and provisional diagnosis. The treating consultant must sign with their bleep number and date. The technologist will provide the number of films and appointment date. The form aims to ensure patient safety by collecting necessary medical information before the MRI scan.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

    Ministry of Health ‫وزارة الصحة‬


    ‫المديرية العامة للشئون الصحية بمنطقة الرياض‬
    Directorate General of Health Affairs Riyadh Region
    ‫مجمع إرادة والصحة النفسية بالرياض‬
    Eradh Complex of Mental Health ‫مركز االحاالت الطبية‬
    Medical Referral Center ‫قسم أهلية العالج والتنسيق الطبي‬
    Department of Eligibility for Treatment and
    Medical Coordination
    MRI REQUEST FORM
    Patient’s Name: Ward/Clinic:
    Nationality: Hospital No:
    SEX:
    Age:

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


    Pregnancy Cardiae Pacemaker

    Surgical Clips Intracranial Vascular Clips

    Artificial Heart Valves Intraocular Metallic F .B


    Joint Prosthesis , Fixation Material Nail, Plate etc.
    IF yes, Please specify whether it is MRI Compatible or Not
    Previous surgery (please specify)
    IF there is any medical illness (specify)
    Level of urea: mmol/l Level of creatinine : umol/l

    Examination Requested:

    Clinical Details and Provisional Diagnosis:

    Department of Eligibility for Treatment and Medical Coordination

    Treated Consultant Signature/Stamp: Date: / /


    Bleep #
    Technologist Name: No. of Films Appointment on:
    Date: / /

    -This form must be completed by the referring clinician (specialist / Consultant) related to his specialty who is responsible for ensuring that the details
    are correct Failure to comply may result, in the patient’s safety being compromised.

    -patient to bring all related previous X-Rays and Reports.

    You might also like