Mri Consent Form

 

Patient ID

 

 

 

 

 

 

MRI Consent/Screening Form

 

 

 

Fax   c ompleted   f orm   t o   4 16-­‐864-­‐5114

 

 

Patient   N ame:

M RN:  

( Please   P rint)  

 

 

 

 

 

DOB:

Weight:

:  

 

( D/M/Y)

( Kg)

Floor/Room

( Inpatients   o nly)

 

During   t he   M RI   E xamination,   y ou   w ill   b e   e xposed   t o   a   v ery   s trong   m agnet.  

The   f ollowing   i tems   c an   i nterfere   w ith   t he   M R   I maging   a nd/or   b e   a   s afety   h azard   d uring   t he   s can.      

 

Incomplete   f orms   w ill   n ot   b e   a ccepted   a nd   w ill   d elay   a ppointment   b ooking.

 

Yes   No    

Yes   No  

1.   H ave   y ou   e ver   h ad   a n   M RI?  

 

 

6.   A re   y ou   d iabetic?  

 

 

2.   H ave   y ou   e ver   h ad   a n   e ye   i njury   t hat   r equired   y ou   t o  

 

 

7.   D o   y ou   h ave   a   h istory   o f   k idney   d ysfunction   o r  

 

 

see   a   d octor   t o   r emove   a   p iece   o f   m etal   f rom   y our   e ye?  

have   a   s ingle   k idney?  

3a.   H ave   y ou   w orked   ( professionally   o r   h obby)   a s   a  

 

 

8.   A re   y ou   o ver   t he   a ge   o f   7 0?  

 

 

welder,   m etal   g rinder,   o r   m etal   c utter?  

9.   A re   y ou   c laustrophobic?    

 

 

 

MRI   w ill   n ot   p rescribe   n or   d ispense   s edation.

3b.   I f   y es,   s ince   y our   p revious   M RI?   ( If   a pplicable)  

 

 

3c.   I f   y es,   w as   e ye   p rotection   a lways   w orn?  

 

 

10a.   D o   y ou   r equire   a n   i nterpreter?  

 

 

10b.   I f   y es,   f or   w hich   l anguage?   _ ___________  

4.   A re   y ou   p regnant   o r   b reastfeeding?  

 

 

 

5.   D o   y ou   h ave   a ny   o f   t he   f ollowing?  

Yes   No    

Yes   No  

Cardiac   p acemaker  

 

 

Penile   i mplant  

 

 

Pacing   w ires   ( epicardial)  

 

 

Breast   t issue   e xpander  

 

 

Implantable   d efibrillator   ( ICD)  

 

 

Eye   p rosthesis   o r   i mplant  

 

 

Neurostimulator/TENS   u nit  

 

 

Metal   r ods,   p ins,   s crews,   w ires  

 

 

Cochlear   ( middle   e ar)   i mplant  

 

 

Surgical   s taples/metal   s utures  

 

 

Swan   G anz   l ine  

 

 

Shrapnel,   b ullet,   B B   p ellet  

 

 

Brain   a neurysm   c lip  

 

 

Hearing   a id  

 

 

Intravascular   s tent,   f ilter,   c oil  

 

 

Dentures,   p artial   p late  

 

 

Shunt  

 

 

Tattoos,   p ermanent   m ake-­‐up  

 

 

Artificial   h eart   v alve    

 

 

Body   p iercing(s)  

 

 

Drug   ( IV)   i nfusion   p ump   o r   m onitor  

 

 

Medication   p atches  

 

 

List   a ll   p revious   s urgeries   a nd   i mplants:      

Include   d ate   a nd   l ocation   o f   s urgeries   t o   e nsure   M RI   c ompatibility.   I mplant   m odel/serial   n umbers   m ay   b e   r equested.  

 

 

 

 

I   a ttest   t hat   t he   a bove   i nformation   i s   c orrect.   I   h ave   r ead   a nd   u nderstand   t he   c ontents   o f   t his   f orm.   T he   p rocedure   h as  

been   e xplained   a nd   I   h ad   t he   o pportunity   t o   a sk   q uestions.  

__________________  

Completed   b y:       P atient/Self                   P hysician/RN                   R elative/Legal   G uardian:   R elationship   t o   p atient

Signature:______________________________________________                                       D ate:_________________  

 

Reviewing   M RI   T echnologist:   _ _____________________________                                         D ate:   _ _______________

BEFORE   E XAMINATION,   P LEASE   R EMOVE   E YE   M AKE-­‐UP,   J EWELLERY,   H AIR   A CCESSORIES,   B ODY   P IERCINGS,   W ATCH,   C REDIT  

CARDS,   C OINS,   K EYS   A ND   O THER   M ETALLIC   I TEMS  

Form No. 69239 Dev. 03/16/2011 Rev. 12/13/2013

MRI CONSENT/SCREENING FORM