MRI Safety Form: model

MRI SAFETY FORM

MRI is simple, safe and painless.  However, because we use strong magnets during the procedure, metal objects in your body may be hazardous or cause interference.  Please provide us with this important information before entering the MRI department.

Name________________________________  Age__________  Weight___________

Have you ever had an MRI?   YES_____  NO_____             Date of last MRI:  ____________

Have you ever had surgery?   YES_____  NO_____ If Yes,  please list all procedures and dates.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any of the following items in your body:

Pacemaker                              YES_____  NO_____ Implanted electrical device      YES_____  NO_____

Ear / Cochlear implant             YES_____  NO_____ Neurostimulators                     YES_____  NO_____

Brain / aneurysm clips             YES_____  NO_____ Stents                                      YES_____  NO_____

Metal in eyes                           YES_____  NO_____ Tissue expander                     YES_____  NO_____

Metal fragments or shrapnel   YES_____  NO_____ Magnetic dental implants        YES_____  NO_____

Any other metal objects or implants______________________________________________________________

If known, please give name and date of implant.____________________________________________________

Have you ever had an injection of contrast for an MRI?                                                         YES_____  NO_____

If Yes, did you experience any of the following:          Hives:                                      YES_____  NO_____

                                                                                                Shortness of breath:                YES_____  NO_____

                                                                                                Fainting or collapse:                YES_____  NO_____

                                   

Female patients:          Is there any possibility of pregnancy?             YES_____  NO_____

                                    Are you breast-feeding?                                  YES_____  NO_____

Sometimes MRI requires an injection of contrast.  MRI contrast (gadolinium) is administered through a small needle placed into a vein.  During the administration of MRI contrast (gadolinium), you may experience the sensation of the contrast being injected, which is normal and expected.

MRI contrast (gadolinium) is quite safe, however as with all medications, there is a slight risk of an allergic reaction.  The physicians and staff in the MRI Department are trained to respond to any emergency situation that may develop.  In addition, we use the safest MRI contrast, which our physicians believe is best for you.

I have read and understand the above information. 

Signature_____________________________ Relationship to pt._____________________ Date_____________