Forms

Referral Sheet
If you do not have a requisition already, your Doctor prefers using our requisition form or you are using a Chiropractor as the referring Doctor, use this form
Referral Sheet.pdf
Adobe Acrobat document [40.5 KB]
Patient Intake Form
This is a general patient information form we need filled out before you can have your scan. We greatly appreciate if you could fill it out before your appointment and email it back to your customer service representative. If you have any questions please contact us.
pembina-mri-patient-intake-form.pdf
Adobe Acrobat document [80.3 KB]

Symptomatic Forms

These forms give our doctors backround information so they can better diangose your injury or condition.  Please chose the form that is appropriate for the scan you are having.

symptomatic-spine.pdf
Adobe Acrobat document [127.1 KB]
symptomatic-hand-wrist.pdf
Adobe Acrobat document [118.9 KB]
symptomatic-head.pdf
Adobe Acrobat document [147.9 KB]
symptomatic-hip-thigh.pdf
Adobe Acrobat document [127.5 KB]
symptomatic-knee.pdf
Adobe Acrobat document [123.3 KB]
symptomatic-leg-ankle-foot.pdf
Adobe Acrobat document [126.7 KB]
symptomatic-shoulder-arm-elbow.pdf
Adobe Acrobat document [122.7 KB]

Contact Us

Pembina High-Field MRI
652 ND-59

Pembina, North Dakota 58271

 

Phone: +1 701 335-7742+1 701 335-7742

 

Email: info@pembinamri.com

 

Or use our contact form.