MRI Safety Questionnaire and Instructions for MRI/MRV/MRCP & MR Arthrogram

"*" indicates required fields

07/27/2024
Name*
MM slash DD slash YYYY
MM slash DD slash YYYY
Is this work related?*

Please provide a “yes” or “no” answer for every item.

Cardiac pacemaker/defibrillator/ICD*
Aneurysm clip(s)/metal stent*
Internal electrodes or wire*
Bone growth stimulator, DBS, VNS*
Magnetic implant or IVC Filter*
External drug pump*
Spinal fusion and/or halo vest*
Any chance you are pregnant*
Ear implant, middle ear implant*
Medication patch*
Implanted drug pump/insulin pump*
Wigs, hair implants*
Tissue expander (breast)*
Hearing Aid(s)*
Eye injury from a metal object*
Ankle monitor*
Injured by metal (shrapnel,bullet)*
Artificial eye and/or eyelid spring*
Neurostimulator or Biostimulator*
Shunt/Sophy pressure valve*
Spinal fixation device or stimulator*
Any metal inside or outside of body*

Instruction for the Patient, Parent or Guardian:

1. Remove all jewelry and all body piercing jewelry and all hair accessories.
2. Remove all dentures, partial dental plates, retainers (for brain, head or neck examinations).
3. Remove hearing aids and eyeglasses and bobbie pins.
4. Remove wallet and anything in your pockets.
5. Remove wigs ( for brain, head or neck examinations).
6. Lock your clothes and valuables in the locker or room provided and remove the key.
*

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PALM HARBOR MRI
32615 US Hwy 19 North
Palm Harbor, FL 34684
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