CT Safety Questionnaire "*" indicates required fields 09/08/2024Name* First Last Email* DOB* MM slash DD slash YYYY MRN#* Safety Question ( for women only): Any chance you are pregnant? Yes No Do you have a history of cancer? Yes No What type? Instruction for the Patient, Parent or Guardian: We will provide a locker or changing room so all items you remove may be stored and locked safely during your scan. You may bring the key in the scan room with you. 1. Remove any jewelry, body piercings, or hair accessories in the area of the examination. 2. Remove dentures, partial dental plates, retainers (for brain, head or neck examinations). 3. Remove hearing aids and eye glasses (for brain, head, neck examinations). 4. Lock your clothes and valuables in the locker or room provided and remove the key.* I attest the above information is correct to the best of my knowledge. I have read and understand the entire contents of this form and I have had the opportunity to ask questions regarding the information on this form.