Imaging Center Forms and Appointments

In an effort to save time at your next diagnostic imaging appointment, please print, complete and bring the applicable form(s) below to your scheduled visit at Beaumont.

Please read on to determine which form(s) you need to complete.

Personal Medication Record (PDF)

MRI Appointment Forms

MRI Patient Screening (PDF) - For all patients receiving an MRI exam

MRI Examination Questionnaire (PDF) - For patients receiving an MRI specifically for cervical spine, thoracic spine, lumbar spine, entire spine, sacral spine, neck, soft tissue neck, carotids, neck MRA, sacral/lumbar/cervical plexus, brain or skull

MRI Body/Muscle Skeletal History (PDF) - For patients receiving any other MRI/MRA exam not listed above

MRI Shoulder Questionnaire (PDF) - For patients receiving a MRI for the shoulder

MRI Knee Questionnaire (PDF) - For patients receiving a MRI for the knee

CT Scan Appointment Forms

Imaging History Questionnaire (PDF) - For all patients receiving a CT exam with contrast

Imaging Procedure Safety Assessment (PDF) - For all females receiving an outpatient CT exam

CT Shoulder Questionnaire (PDF) - For patients receiving a CT exam for the shoulder

CT Knee Questionnaire (PDF) - For patients receiving a CT exam for the shoulder

Mammography Appointment Forms

Patient Information - Division of Breast Imaging (PDF) - For all patients receiving a mammogram