MRI Screening Form

MRI Screening Form
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Weight
Height
Gender
Postmenopausal
Referring Doctor's Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Body Part to be Examined
Reason for MRI
Please answer the following questions. Please take note that any of the following may affect the results of your MRI or can be hazardous to your safety

Please answer if you have any of the following:

Rows	Yes	No
Aneurysm Clip(s)
Any metallic fragment or Foreign Body, Including Bone/Join Pin, Screws, Plates, Wires, Wire Mesh Implants, etc.
Artificial or Prosthetic Limb
Body Piercing Jewelry
Bone Growth/Fusion Stimulator
Cardiac Pacemaker
Cochlear, Otologic, or other Ear Implant
Dentures or Partial Plates
Electronic Implant or Device
Eyelid Spring or Wire
IUD, diaphragm, or Pessary
Implanted cardioverter defibrillator (ICD)
Insulin or Other Infusion Pump
Implanted Drug Infusion Device
Joint Replacement (hip, knee, etc.)
Magnetically-activated implant or device
Medication Patch (Nicotine, Nitroglycerine)
Metallic Stent, Filter, or Coil
Neurostimulation system
Prosthesis (eye, penile, heart valve)
Radiation Seeds or Implants
Shunts and/or Stents (spinal or Intraventricular)
Spinal Cord Stimulator
Surgical Staples, Clips, or Metallic Sutures
Swan-Ganz or Thermodilution Catheter
Tissue Expander (e.g., breast)
Tattoo including Permanent Makeup
Vascular Access Port and/or Catheter
Wires or Internal Electrodes
Hearing Aid
Claustrophobia
Breathing problems
Motion Disorders
Allergic to Drugs, Food, MRI, or CT Contrasts
Sickle Cell Anemia

Please explain if you have other implants not specified above
I hereby declare that I have answered the questions above in full honesty and to the best of my knowledge. I understand that any removable metallic items I am wearing must be removed prior to the MRI scanning procedure. I understand and acknowledge that the failure to remove any metallic items may result in serious damage or injury to me and to others.
Signature
Clear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

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