Royal Oak MI 48073 Phone 248 435-8066 Fax 248 435-8099 Patient Information Date Patient s Name Sex M F Age Claustrophobic Y N Referring Physician Information Name Phone No* Address City Please Notify Basha Diagnostics Staff if the patient needs transportation* 248 435-8066 Each patient will receive a complimentary CD of their study - upon request. com Please contact the Royal Oak 13 Mile Clinic for ALL MRI Scheduling. 30701 Woodward Avenue Suite LL 248 288-1600 FAX 248 288-2171 FOR BILLING AND INSURANCE INQUIRIES CONTACT. MRI LOCATIONS M-59 dw ar Garfield ld Hayes ica Ut fie Green Coolidge Van Dyke d Ca ss I-696 Royal Oak Clinic Sterling Heights Clinic 13753 19 Mile Rd. Other Head Abdomen Brain MRI Contrast Circle Attention To IAC s Sinuses Pituitary Carotids MRA Orbits Neck - Soft Tissue Thyroid Palpable Mass Liver / Spleen Kidneys Pancreas Gallbladder / Biliary Adrenal Entire MRA MRV Extremities Shoulder Hip Knee Ankle Foot Elbow Wrist Hand L R TMJ L R Contrast Enhanced MRA Spine Complete Cervical Thoracic Lumbar Sacral Renal Arteries Aorta Lower Extremities MRV-Lower Extremities Other Pelvis Brachial Plexus Specify MUST BE COMPLETED BY ORDERING PHYSICIAN Rule out Diagnosis Clinical Information REQUIRED BY BLUE SHIELD OF MI FOR ALL B/S PATIENTS Physician s Signature Form 202 oo W I-75 ks 14 Mile Schoenherr M-53 Croo Southfield Romeo Plank BASHA DIAGNOSTICS P. Appointment Date MRI Appointment Time Head Chest Complete Spine Pelvic and Abdominal Upper and Lower Extremities. CLINIC STERLING HEIGHTS CLINIC DEARBORN ROEMER CLINIC MEDICAL RECORDS/ADMINISTRATION 248 435-8066 586 566-8680 313 584-0768 FAX 313 945-9339 248 288-1600 FAX 248 288-2171 Open MRI MRI/MRA Imaging Center MRI APPOINTMENT IN 24-48 HOURS com Please contact the Royal Oak 13 Mile Clinic for ALL MRI Scheduling. Roemer Charles Lapham Basha Diagnostics Medical Records Administrative Office Dearborn Clinic 4407 Roemer Dearborn MI 48126 313 584-0769 Fax 313 945-9339 Greenfield Rd.
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