EAST RIVER MEDICAL IMAGING. PC MAGNETIC RESONANCE IMAGING IMRI) Patient Name; EPSTEIN. JEFFREY MRN #: 0315192 Age: 65 Years Sex: M Height Feet Inches Weight Referring Physician: MOSKOVVITZ, BRUCE W. M.D. M.D. Exam Code: MRCLAVL lbS Exam Date: 06/05/2018 Ace* 7156124 IMPORTANT: Please notify the receptionist if you answer "YES" to any of the questions below. The receptionist will inform the technologist/radiologist of your response. YE? N PLEASE CHECK: uu Have you had metal removed from your eyes? 0 Have you been shot with bullets. BB's or shrapnel? CI Are you pregnant? O Are you nursing? 0 Are you on hemodialysis or peritoneal dialysis? O Do you require oxygen or an inhaler? O Do you have renal disease? If yes please describe O Are you wearing any metallic items? O Any surgery on the area to be imaged? If yes. when? O Any surgery on your eyes, ears brain or heart? O Have you had a Colonoscopy and/or Endoscopy within the last 6 weeks? If yes. date of exam YES NO DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? 0 Brain/Aneurysm Clips 0 Pacemaker, Pacer Wires or Defibrillator if yes. make% year O Any Metallic fragment or foreign body O Ear Implants or Hearing Aids O Electrical Stimulators O Implant/Prosthesis O Infusion Pumps 0 Coils. Catheters. Filters or Wires in blood O Artifical Limbs or Joint Replacement O Tattooed Eyeliner O Artificial Heart Valves O Stents If yes, please provide date of implant: O Magnetic Dental Implants O Transdermal Patches 0 IUD O Tissue expander for future implants O Bone Stimulators. Insulin Pumps. or Mechanical Valves O Programmable Shunts WARNING: fore entering the MR room, you must remove all metallic objects including HEARING AIDS, DENTURES, CREOIT/BANK CARDS, watch, keys, cell phone, beeper, hair pins, barrettes, body piercing jewelry, money clips, magnetic strip cards, pe pocket knife, and nail clipper. Please consult the technologist if yo any questions or ncems BEFORE you enter the MR room. Signature: Print Name: Tr---Fmeey EFSTej,4 Date: 06/05/2018 Patient Complaint/Diagnosis: Technologist's Use Only Any previous imaging studies in this area? O YES O NO If yes, where? Technologist: Wet Read:nq K "ES Q NO Dr's Phone Number. NPF0 Gasbonnalte 09-2013 2000 /1'000 IYA xv TZ:9 9TOZ/OC/g0 EFTA00313968