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
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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.
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