MRI Patient Safety Questionnaire

MRI Patient Safety Questionnaire Form

Please enable JavaScript in your browser to complete this form.
IMPORTANT: You will be entering a strong magnet for your MRI scan and some implanted devices can cause you harm. It is very important that you provide a "Yes" or "No" answer to each of the following questions.

Surgically implanted medical devices. Please select the answers below.

If you have answered YES to any of the below questions, please speak to the reception staff.


Have you ever had, or do you have any of the following?
Female Patients

MRI CONTRAST ADMINISTRATION

To define and detect abnormalities on your MRI scan, you may require a Gadolinium contrast injection. Although it is very rare, there is always a possibility of side effects or reactions to the contrast injection which can result in hives, rash, or facial swelling. However, severe reactions are rare.


Declaration
Clear Signature