Smart Choice MRI- Community Service

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Please complete the form below if you are interested in receiving an MRI at no cost to you.

Important:
We anticipate that there will be many more requests than scan times available so, it will be required that you provide all of the requested information. Entries will be selected based on availability and pre-determined qualifying factors. Only patients under the care of a doctor with a valid order can be considered. MRIs cannot
be performed without the direction of a physician, Chiropractor, Nurse Practitioner or Physician’s Assistant.

Information about You

Name:
Address:
Daytime telephone Number:
Date of Birth (mm/dd/yyyy):

Information about your Doctor and the Exam that You Need

Name of treating practitioner:

Office Phone number:

Do you have a physician’s order?

Yes

Type of MRI requested
(type in exactly what the order says):

Information about your Unemployment and Insurance Status

Last Date of Employment (mm/dd/yyyy):
Date that Unemployment Claim was approved (mm/dd/yyyy) (Please be prepared to supply a copy of your approved claim):
Previous Employer:
Previous Insurance Company:
Date coverage lapsed or laspses (mm/dd/yyyy):
Any other information you would like us to consider:

PRIVACY STATEMENT

Smart Choice MRI LLC does not collect any personal data on persons visiting this website. If you choose to contact us through e-mail or by submitting forms through US Mail, the information you provide will only be used by Smart Choice MRI LLC for correspondence. Your information will then be destroyed and will not be given or sold to any other companies or individuals.