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Mon - Thurs - 7:00 AM - 9:00 PM
Friday - 8:00 AM - 5:00 PM
Saturday - 7:00 AM - 7:00 PM

Medica Stand-Up MRI of Birmingham
3105 Independence Drive
Suite 101
Homewood, AL 35209

Phone: 205-871-3335
1-888-4-YOUR-MRI (496-8767)
Fax: 205-871-3305

Click here for directions.

Referral Form

Prefer to email, fax or mail your order form in? Please click here to download a PDF of our referral form.
* = Required Fields
General Information
*Date Ordered:
*Patient Name:
*DOB:
*Patient Contact Number:
*Primary Insurance Company:
*Primary Insurance Policy Number:
*Referring Physician:
*Office Phone Number:
Procedure Ordered
MRA:
MRV:
Brain:
Spine:	Flexion: Extension: LT Bend: RT Bend:
Lower Joint:
Upper Joint:
Lower Extremity:
Upper Extremity:
Other:
Patient History
Pacemaker?
Pregnant?
Aneurysm Clip?