iCare Physicians MRI Referral Form

Pacemaker

Metal Braces

Implated Device(s)

Metal in Body (where):

Confirm

Disc Injury

Tumor/Growth

Muscle/Tendon Injury

Rule Out

Stenosis

Degeneration

Evaluate

Pain Management Consulting

Joint Injection

Trigger Point Injection

PRP (Platelet-Rich Plasma)

Neck Pain

Headache/Dizziness

Slip & Fall

Lumbar Pain

Work Injury

Sciatica/Leg Tingling/Numbness/Pain

Auto Injury

Decreased ROM

Muscle Spasm

Thoracic Pain

Arm Tingling/Numbness/Pain

iCare Diagnostic Imaging