Implanted Stimulator MRI Checklist
Complete this checklist before scheduling or performing an MRI on a patient with an implanted stimulator device.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Physician Name
*
First Name
Last Name
Type of Implanted Stimulator
*
Please Select
Spinal Cord Stimulator
Deep Brain Stimulator
Vagus Nerve Stimulator
Sacral Nerve Stimulator
Other
Device Manufacturer and Model
*
Date of Device Implantation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the patient have an MRI safety card for the device?
*
Yes
No
Is the implanted stimulator MRI-conditional or MRI-safe according to manufacturer guidelines?
*
MRI-Conditional
MRI-Safe
Not MRI-Compatible
Unknown
Checklist for MRI Safety Assessment
*
Rows
Yes
No
N/A
Device programmed to MRI-safe mode (if applicable)
1
2
3
All external device accessories removed
4
5
6
No signs of device malfunction or infection
7
8
9
Patient is not pregnant
10
11
12
No other implanted metallic devices
13
14
15
Describe any symptoms, complications, or concerns related to the device or MRI procedure
Patient/Guardian Signature
*
Submit Checklist
Submit Checklist
Should be Empty: