iCare Diagnostic Imaging

Physicians Referral Form

2781 Freeway Blvd #160, Minneapolis, MN 55430

Phone: (763) 244-8020 | Fax: (763) 244-8021

Email: scheduling@icaremri.com

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Physicians Referral Form

Alerts

Reason For Exam

MRI STUDY SELECTION

GENERAL MRI

70551
72141
72146
72148
72195
74181

UPPER EXTREMITY

73221
73221
73221
73218

LOWER EXTREMITY

73721
73721
73721
73718

MRA (ANGIOGRAPHY)

70544
70548
74185
71555
72196
73725

Pain Management/Injections (via Shingle Creek Medical Group)

X-Rays Upright & Weight Bearing

Cervical Spine

Thoracic Spine

Lumbar Spine

Upper/Lower Extremities

Type Of Trauma

(Print a copy for your records? Hit "Download PDF" before hitting "Submit Form" to send it to us. Thank you!)