Mri Screening Form (Page 2 of 2) in pdf

PREGNANCY STATUS

Are you: Pregnant?

YES

NO Possibly Pregnant?

YES

NO Breast Feeding?

YES

SKIN WARMING

*MRI Radiofrequency has the potential to cause tissue heating. The Technologist will take several precautions to

avoid this. Alert the technologist immediately if you notice any heating sensation during your MRI scan.

TATTOOS AND PERMANENT MAKEUP

*A small number of patients with tattoos have experienced transient skin irritation, swelling, or heating sensations

at the site of the permanent colorings in association with MR procedures. Individuals with tattoos or permanent

makeup should inform the Technologist so appropriate precautions can be taken.

I attest that the information on this form is correct to the best of my knowledge. I have read and understand the

contents of this form and had the opportunity to ask questions regarding the MR procedure I am about to

undergo.

Patient/Guardian Signature: ________________________________________ Todays Date: __________________

Print Name: _______________________________

Technologist Signature: ____________________________

CONTRAST CONSENT

Due to your medical history or as requested by your Physician, an injection of MRI contrast (Gadolinium) may be

necessary to aid the radiologist in evaluating your MRI scan. The Food and Drug Administration has approved this

agent. A very small percentage of patients receiving Gadolinium may develop a headache or experience mild

nausea. As with all medications, there is a slight risk of an allergic reaction. The physicians and staff at Pain

Specialists are trained to respond to any emergency situation that may occur within the MRI Department.

Check YES or NO to each item.

DO YOU HAVE

YES

NOTES

Kidney Function Problems

Liver Function Problems

Asthma or any Respiratory Disease

Diabetes

Have you ever had an allergic reaction to MRI/CT contrast? Y / N If yes, what type? ________________________

______________________________________________________________

Please list ALL known allergies

I CONSENT to having Gadolinium contrast as needed

I DECLINE having Gadolinium contrast injected at this time

Patient/Guardian Signature_______________________ Technologist Signature____________________________

Mri Screening Form Page 2