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_____________