MRI Safety Compliance Survey
Please complete this survey to ensure your safety and compliance before undergoing an MRI scan.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Phone Number
*
Please enter a valid phone number.
Do you have any of the following? (Select all that apply)
*
Pacemaker or defibrillator
Cochlear implant
Metal fragments or shrapnel in body
Aneurysm clips
Prosthetic joints or artificial limbs
None of the above
Other
Are you currently pregnant or possibly pregnant?
*
Yes
No
Not applicable
Do you have any known allergies (e.g., to contrast agents, medications, latex)? If yes, please specify.
Submit Survey
Should be Empty: