Name (required)

Referring Physician (required)

Phone (required)

Current Weight (in pounds) (required)


Please indicate if you have had any of the following implanted devices: (required)

Brain aneurysm clip(s)
YesNo

Cardiac pacemaker
YesNo

Cardiac defibrillator
YesNo

Any electronic device
YesNo

If yes, explain:

Any magnetically-activated device
YesNo

If yes, explain:

Have you ever had surgery to replace or implant anything in your body? (heart, eyes, ears, joints, reproductive organs, or any other body part, etc.) (required)

YesNo

If yes, explain:

Have you ever been injured by a metallic object or foreign body? (BB, shrapnel, bullet, fragment in the eye from welding, etc.) (required)

YesNo

If yes, explain:


Email

Date of Birth

Insurance Company

Insurance ID#

Extremity

Preferred Day #1:

Preferred Time #1:

Preferred Day #2:

Preferred Time #2:

Preferred Day #3:

Preferred Time #3:

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