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MRI Form

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Are you claustrophobic?
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Do you have a PACEMAKER?
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Do you have any IMPLANTS?
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If yes, please list when and where it was done:
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Metallic slivers, shavings, foreign body, etc.
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NOTE: *Orbit X-rays may be needed prior to MRI to rule out any possible metal left behind for your safety. If these X-rays have been done in the past, please bring the radiology report.
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BB, bullet, shrapnel, etc.
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For female patients only
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For female patients only

Do you have any of the following? Please circle yes or no to each question:

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***You must bring ID card AND controller***
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(*must be removed*)
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*Most are unsafe; bring ID Card*
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(***Remove before entering MRI room***)
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NOTE: Before entering the MRI Room, you must remove all metallic objects and clothing with metallic threads, snaps, etc. Please consult the MRI Technologist if you have any questions or concerns BEFORE you enter the MRI system room.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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