The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

gzQpGc6GWrEuLttAyIG2DmELskq4HwB5EsGmJ9jGBXfQcNr3xgxahWaN3UfuILVhsPZZCVm

Welcome to Mount Sinai Radiology

Please complete the Pre-registration Forms for your Imaging Appointment.

Your information is encrypted and will be stored in our secure database.

Thank you!

Date of imaging appointment:

* must provide value

M-D-Y

Patient Last Name:

* must provide value

Patient First Name:

* must provide value

Patient date of birth:

* must provide value

M-D-Y

Patient Age:

* must provide value

View equation

Insurance Gender (Gender selected under insurance):

* must provide value

Gender Preferred Pronoun:

Patient Mailing Address:

* must provide value

Expand

Patient Phone Number:

* must provide value

Patient Weight:

* must provide value

Pounds/Lbs

Kilos

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Patient Height:

* must provide value

feet-inches

centimeters

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Referring Physician:

Medical Record Number (MRN):

Identify the location where your imaging will be occurring:

* must provide value

MS RA 1176 5th Ave

MS Hess 1470 Madison

MS West 425 W 59th

MS Doctors 34th St

MS Downtown Chelsea Center 15th St

MS Union Square

MS Queens

MS Brooklyn Heights

MS Kingsway

MS Doctors Long Island

MS Morningside 1090 Amsterdam Ave

MS Petrie 281 1st Ave

MS 1184 5th Ave (Peds/Nuclear Medicine)

MS West 1000 10th Ave (PET/CT)

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Please select which visit you are having today:

* must provide value

Initial Visit

Follow-up visit

Unsure

Imaging to be completed at appointment (choose all that apply)

* must provide value

Bone Density (DEXA)

CT (Computed Tomography, CAT Scan)

MRI (Magnetic Resonance Imaging)

PET (Positron Emission Tomography)

Ultrasound (Sonogram)

X-Ray (Radiograph)

Nuclear Medicine

Biopsy

Test with contrast

Other

Are you getting a radiology study of one of the following: shoulder, arm, wrist, hand, hip, leg, knee, ankle or foot?

* must provide value

Yes

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If Other, please describe

* must provide value

You indicated you are getting a CT scan. Does the scan involve contrast?

* must provide value

Yes

Not Sure

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If FEMALE, are you pregnant or do you think you are pregnant?

* must provide value

Yes

Not Sure

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Did you require assistance in completing this questionnaire and will you continue to require assistance to complete other questionnaires?

* must provide value

Yes No

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Indicate relationship to Patient

* must provide value

Patient (self)

Relative/Parent/Guardian/spouse

MD/Physician/clinician

Other

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Name of individual completing this questionnaire:

* must provide value

Signature of individual completing this questionnaire:

* must provide value

Add signature

Date questionnaire is completed:

* must provide value

M-D-Y

PLEASE MAKE SURE TO REVIEW ALL QUESTIONS AND ANSWERS BEFORE SUBMITTING

PLEASE NOTE: ADDITIONAL FORMS WILL NEED TO BE COMPLETED ONCE THIS PAGE IS SUBMITTED.

THE FOLLOWING PAGE WILL CONTAIN THESE FORMS.

PLEASE ACKNOWLEDGE WITH A YES RESPONSE.

* must provide value

Yes

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FOR INTERNAL USE ONLY

If individulal assisting patient is a RN or MD, will information to complete questionnaires be corroborated by chart history?

Yes No

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.