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ONLINE PRESCRIPTION FORM

WELLNESS ASSOCIATES OF FLORIDA OFFERS AN ONLINE PRESCRIPTION FORM

FOR FAST AND EFFICIENT MRI SCAN REFERRALS

EMPIRE IMAGING RX

PATIENT INFORMATION

First Name *

Last Name *

Date of Birth/D.O.B *

Phone *

Social Security

Email

REFERRING DOCTOR

Doctor Name *

Diagnosis

Rule Out

Dr Signature *

Dr Signature

APPOINTMENT REQUESTED

Appointment Date

Appointment Time

AM/PM

AM

PM

Transportation Needed

YES

NO

INSURANCE INFO

Insurance Company

Insurance Phone

Date of Accident

Policy Number

Claim Number

ATTORNEY INFO

Attorney

Atty Phone

Paralegal

TREATMENT PROCEDURES

MRI Areas

Abdomen

Ankle

Biceps

Brain

C-Spine

Elbow

Femur

Fingers

Forefoot

Hindfoot

Hip

Humerus

IACs

MRA

Brain/COW

Arterial

Venous

MRI Areas 2

Knee

Liver

L-Spine

Orbits

Pelvis

Pituitary

Radius/Ulna

Shoulder

ST-Neck

Tibia/Fibula

Toes

Wrist

DTI Scan

NeuroQuant

TBI

MRI Extras

CONTRAST

With

Without

W & W/O

EXTREMITY

Upper

Lower

Right

Left

Bilateral

RECONS

3-D

Sagittal

Coronal

OTHER INSTRUCTIONS

Call Us 561-861-1388, We will do our best to help you get the best affordable and accurate Open MRI, 1.5T and 3T High Field MRI and Standing MRI near you.

We have MRI centers in Kendall (Miami), Hialeah, Pembroke Pines and West Palm Beach ready to Serve You!

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