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Monday - Friday
8:30 AM - 5:00 PM
Call for an appointment:
706.782.0770
Medica Rabun
7499 Old Hwy 441 South
Lakemont, GA 30552
Phone: 706.782.0770
Fax: 706.782.1091
Click here
for directions.
Referral Form
Prefer to email, fax or mail your order form in? Please
click here
to download a PDF of our referral form.
* = Required Fields
General Information
*Date Ordered:
*Patient Name:
*DOB:
*Home Phone Number:
*Cell Phone Number:
Primary Insurance Company:
Primary Insurance Policy Number:
Primary Insurance Group Number:
Secondary Insurance Company:
Secondary Insurance Policy Number:
Secondary Insurance Group Number:
*Referring Physician:
*Referring Tax ID:
*Office Phone Number:
Procedure Ordered
MRI Cervical Spine:
Select
Yes
No
Select
No Contrast
With Contrast
With & Without Contrast
MRI Thoracic Spine:
Select
Yes
No
Select
No Contrast
With Contrast
With & Without Contrast
MRI Lumbar Spine:
Select
Yes
No
Select
No Contrast
With Contrast
With & Without Contrast
MRI Brain:
Select
Yes
No
Select
No Contrast
With Contrast
With & Without Contrast
MRA:
Select
Yes
No
Select
Head
Neck
Both
MRI Forefoot:
Select
Yes
No
Select
Right
Left
MRI Hindfoot/ankle:
Select
Yes
No
Select
Right
Left
MRI Shoulder:
Select
Yes
No
Select
Right
Left
MRI Knee:
Select
Yes
No
Select
Right
Left
MRI Hip:
Select
Yes
No
Select
Right
Left
MRI Abdomen:
Select
Yes
No
Select
No Contrast
With Contrast
With & Without Contrast
MRI Pelvis:
Select
Yes
No
Select
No Contrast
With Contrast
With & Without Contrast
Has the patient ever had any prior surgery on the area to be scanned?
Select
Yes
No
Patient History
Pacemaker?
Select
Yes
No
Pregnant?
Select
Yes
No
Brain aneurysm clip?
Select
Yes
No
Intra-Uterine Devices (IUD)?
Select
Yes
No
Has pt had STENT surgery in past 6 weeks?
Select
Yes
No
Cochlear Implants?
Select
Yes
No
Implanted stimulator(s)?
Select
Yes
No
Metal in Eyes?
Select
Yes
No
Claustrophobia?
Select
Yes
No
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