Magnetic Resonance Imaging Screening Form

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Personal Information

Name

Date of birth

Sex

Height

feet

inches

Weight

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Previous Scans at CCBBI

Have you ever been scanned at the CCBBI before?

If yes, was it within the previous 12 months?

Primary Care Physician (PCP) Information

PCP/Office Name

PCP/Office Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

To ensure your safety in the MRI scanner, please check if you have any of the following items and answer all questions.

Cardiac pacemaker, implanted cardioverter defibrillator (ICD), heart valve prosthesis, aneurysm clip etc.?

Surgical staples, clips, or metallic sutures etc. from surgery or invasive procedure?

Electronic or magnetically-activated implant: neurostimulator, spinal cord stimulator, bone growth/fusion stimulator?

Drug (insulin or other) infusion device, radiation seeds or implants, or medicated skin patch?

Any type of prosthesis (limb, joint, eye, penile, etc.) or pin, screw, nail, wire, plate, etc.?

Body piercing jewelry, wig or hair extensions, tattoo or metallic microfiber in clothing?

Eyelid spring or wire, permanent eye makeup or microblading, or magnetic eyelashes?

Metallic stent, filter, coil, or Swan-Ganz or thermodilution catheter?

Internal electrodes, wires, shunt (spinal or interventricular) or any other implants?

Have you ever been injured by a metallic object/fragment (BB, bullet, shrapnel, metallic slivers, shavings, etc.)?

Breathing problem or motion disorder?

Claustrophobia?

Answer the next two questions if applicable

Are you pregnant or possibly pregnant?

Do you have an Intrauterine Device (IUD)?

If yes, what brannd?

Before entering the MRI room, you will be asked to remove all metallic objects, including keys, jewelry, watch, and clothing with metal in the material. You will also have ear protection during the MRI scan.

I attest that the above information is correct to the best of my knowledge. I have read and understand the entirety of this form. I confirm that I had the opportunity to ask questions regarding the information on this form.

Date

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