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Imaging, Testing & Procedures
Schedule an MRI
About MRI:
A magnetic resonance imaging (MRI) uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body. These images help doctors diagnose a variety of problems.
If your doctor or provider has ordered an MRI, please use the form below to schedule your exam.
MRI Guidelines
MRI scans require a physician order
To schedule an MRI of the heart or breast call
812-842-3063
Your doctor may place this order electronically, or will provide a paper order from that you should bring with you to your appointment
A scheduling representative will be in contact with you to discuss any special instructions prior to the date of your exam
Step 1: Complete the Form Below
First Name:
Last Name:
Date of Birth (mm/dd/yyyy):
Phone Number:
Type of MRI:
Brain
Neck and Upper Back
Neck and Lower Back
Upper and Lower Back
Spine Complete(Neck, Upper and Lower Back)
Abdomen
Shoulder
Elbow
Wrist
Hand
Hip
Knee
Ankle
Foot
Prostate
Is your ordering physician a Deaconess physician:
Yes
No
Not sure
Ordering Physician:
Have you had any lab work in the past 6 weeks?:
Yes
No
Where were your labs done?:
Please select all of the implants or devices you currently have:
Implants, such as: stents, valves, shunts, coils, filters or ports
Metal, such as: body piercings or metal fragments
External monitoring device or pump
Aneurysm clips
Defibrillator
Insulin pump
Neuro stimulators
Pacemaker
Pain pump
Other
None of the above
Other:
Please select any of the items below that apply to you:
Age 60 and older
Allergies or sensitivities to contrast dyes or iodine
Claustrophobic or very uncomfortable in close spaces
History of kidney disease, kidney cancer or kidney surgery
Kidney transplant or only have a single kidney
Pain Patch, Tattoo w/in last 72 hours, or temporary hair dye
History of diabetes
Pregnant or breast feeding
A personal history of cancer
None of the above
Please enter your height:
Please enter your weight:
Please indicate if you have had any of the surgeries or conditions listed below:
Brain surgery or anything implanted in my brain
Ear surgery or anything implanted in my ear
Surgery in the area that will be scanned
Ever had spine surgery
None of the above
Please explain about your surgery:
Special Care Implants
×
There are certain implants that require special care during an MRI. You have indicated that you have one or more of these devices or implants. Please call
812-450-5250
to schedule an appointment.
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