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PATIENT FORMS

Click to open each PDF form.  Complete each form by typing in your answers. 
Forms can be signed when you come in.  See below for more info on completing and submitting forms.  Email address to submit forms: patient.registration@premiermri4u.com
 
New Patient Forms:
  
 • Patient Registration Form
 •
Patient Screening Form
 •
Patient Informed Consent
 •
Gadolinium Warning & Consent Form
 •
Music Selection Sheet

Forms Related to Specific Body Parts:
 
 • Brain Questionnaire  Important:
    
Brain scans require an additional coil. See picture.
    
 • Cervical/ Thorasic/ Lumbar Questionnaire
 •
Shoulder Questionnaire
 •
Extremity Questionnaire
 •
Knee Questionnaire
 

 
 
   
Your Comfort is Our Goal
       
The Premier MRI scanner is located in our new medical suite.  Our open MRI sets standards for Patient comfort.

Our Staff of certified MRI technologists and board certified radiologists are here to assure your comfort and safety.

If you'd like to visit us, see the MRI, and meet our staff prior to your exam, just call or email.

 
The Premier Difference
 
• Quiet & Non-Claustrophobic
     
• Your favorite music choices
     
• A guest may stay with the patient
   throughout the scan
     
• Eye pads for patient comfort
     
• CD of the study given to each
   patient upon departure

 
 
 

 

7015 Hwy. 190 E. Service Rd., Suite E 100, Covington, LA 70433   •   Tel. 985-809-6744   •    Fax 985-809-6745   •   E-mail
    
Hours:  Mon-Fri 7am - 10pm.  We also offer early morning, evening, and Saturday appointments for your convenience.
   
Copyright © 2011 Premier MRI 4U.  The Northshore's Premier MRI Facility.  Accredited by the American College of Radiology.