MRI Evaluation Request Form
Johns Hopkins Orthopaedic & Spine Surgery at Good Samaritan

For a Complementary Review of your MRI report please complete the form below and fax your MRI report to 443-444-4775.
Please send the report only, and not the MRI films or discs.

Once we have received your report this will be reviewed by a member of our surgical team. A care coordinator will then call you to discuss your symptoms. Typical questions asked can include, “Do you have any arm pain, or leg pain?”, “Is there any numbness present?”, “Any weakness?”

It is important to note that this discussion is a preliminary diagnosis only. A complete physical evaluation as well as a personal review of your MRI images by one of our surgeons will be necessary to determine an appropriate treatment plan tailored specifically to your condition and needs. If you have not heard back from us within 3 business days, please call us at 443-444-4730 for further assistance.

First Name: Last Name: Phone Number: Email Address: Cell Phone: Address: City, State, Zip: SSN: Birthdate: How Would You Prefer To Be Contacted? -Choose From List- Phone Email Other Information: (Please add any other information regarding when you last had an MRI, referring physician name & phone number, & anything else you think we should know.)

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Johns Hopkins Orthopaedic & Spine Surgery at Good Samaritan Hospital
5601 Loch Raven Blvd, Smyth Bldg, Suite G-1, Baltimore, MD, 21239  Phone 443-444-4730  Fax 443-444-4752
www.hopkinsorthogsh.com