MRI SAFETY SHEET

If you are booking in for a MRI scan and would like to save time in the department, please complete the MRI Safety Sheet below. We will store this information securely with your appointment details ready for your arrival.

First Name
Last Name:
DOB:
 /  / 
Age:
Weight (KG):
Referring Doctor:
Body Part To Be Scanned:
Symptoms For MRI Scan:

Do you have, or have you ever had:

A Cardiac Pacemaker or Intra-Cardiac Defibrillator?
An Artificial Heart Valve?
A Cardiac Catheter eg Swan Ganz?
A Cerebral or Intra-Cranial Aneurysm Clip?
A Cerebral (V-P) shunt for hydrocephalus?
Surgery on your Arteries or Veins (coil/stents/filter)?
Ear Implants (Cochlear Implant) or ear surgery?
Occular Prosthesis (Eye Implant)?
Permanent Drug Infusion Pump?
Neurostimulator Muscle or Bone Growth Stimulator?
Any Spinal Operations?
A Joint Replacement or Artificial Limb?
Any Metal Pins, Screws or Plates?
Any Shrapnel or Gunshot?
A Penile Implant?
Dentures, False Teeth or Hearing Aid?
Any Skin Patches (eg Transdermal)?
A Tattoo or Permanent Makeup or Body Piercings?
Any Allergies?
Any Kidney Disease?
Have you ever been a Metal Worker?
Have you ever had metal in your eyes?
... if 'Yes', has all the metal been removed?
Any chance you may be Pregnant?
Do you have an Intra-Uterine Device (IUD)?
Form Completed By:
By selecting 'Yes', I declare that the above information is correct to the best of my knowledge. I also acknowledge and consent that an injection of intravenous contrast may be required. *
Date: