MRI History/Screening

"*" indicates required fields

MRI HISTORY

Date:*

Gender:*

Male

Female

Name*

First Last

Date of Birth:*

Referring Physician:*

Height:*

Weight:*

PATIENT HISTORY

Reason you are here today? (Please list the problem, the area(s) experiencing the problem and when it started)*

Have you had any surgery on the area being scanned?*

Yes

Type/date:*

Any history of trauma or injury in the area we are scanning today?*

Yes

Type/date:*

Do you have a history of cancer?*

Yes

Type/date:*

Any prior imaging/scans on the body part we are scanning today?*

Yes

Type/date/facility name:*

Do you have any food or drug allergies?*

Yes

Pre-medicated specifically for this study today?*

Yes

List all:*

Medication Name(s):*

Time/date of last dose:*

Physician Name who prescribed:*

Have you ever had metal in your eye or removed from your eyes?*

Yes

Please write the areas of your body where you feel pain/numbness/tingling/weakness*

Please write the areas of your body you have implants or metal inside of or on your body*

FEMALE ONLY:

Is there a possibility of pregnancy?*

Yes

Last Menstrual Cycle:*

How Far Along?*

MRI Screening

Do you have any of the following:*

Other implant:*

Make:

Model:

Implant Date:

Make:

Model:

Implant Date:

WARNING: Certain implants, devices, or objects may be hazardous to you and/or may interfere with MR procedure (i.e., MRI, MR angiography).Do not enter the MR system room or MR environment if you have any question or concern regarding an implant, device, or object. Consult the MRI Technologist or Radiologist BEFORE entering the MR system room. The MR system magnet is ALWAYS on. Before entering the MRI environment or MRI system room, you must remove all metallic objects including hearing aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paper clips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners and clothing with metallic threads. Safety risks from Radiofrequency (RF) waves include potential tissue heating and burns. Alert the scanner operator immediately if warming occurs. Please note that some warming is normal but you should never be uncomfortable. Important Note: The noise generated by scanning may reach a level in the scan room and in the bore of the magnet that can result in temporary (and occasionally) permanent hearing loss. Any patient who undergoes an MRI, as well as anyone in Zone 4 during a Scan, MUST wear hearing protection. Your exam may be monitored for quality assurance.

I aftest that the above information 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 information on this form and regarding the MRI procedure I am about to undergo.

Signature of person completing form:*

Date:*

Form Completed by:*

Patient

Relative

Nurse/Caregiver

Printed Name:

Consent for Gadolinium-based IV Contrast:

Name:*

Date of Birth:*

Some patients undergoing an MRI scan may require an intravenous (IV) dye (contrast) known as Gadolinium. There are many benefits of using IV contrast for an MRI. It improves accuracy, assists in diagnosing abnormalities and may help direct your treatment. As with all drugs or medications, there are risks; however, the benefits usually outweigh the small chance of side effects or reactions. The decision to give you IV contrast is not taken lightly and is carefully made by your referring doctor and/or our radiologist. Most injections of IV contrast occur without any issues. A rare, but possible side effect from IV contrast injections is extravasation. Extravasation means that the contrast material went outside the blood vessel and has gone into the surrounding tissue. Extravasation may result in a stinging or burning sensation, and/or tightness or swelling at the injection site. Minor contrast reactions are the most common, but happen in less than 0.05% of cases. Symptoms may include headache, sneezing, nausea, vomiting, hives and swelling and usually resolve rapidly. Occasionally medications may be required to help treat these symptoms if they persist. Rarely, a severe reaction can happen. This may include a rapid or slow heart rate, low blood pressure, an asthma attack (bronchospasm) or complete circulatory arrest/shock. Such reactions require urgent medical treatment, which our offices are prepared to handle. If you have ANY symptoms that concern you, please tell your technologist promptly. Patients with reduced kidney (renal) function or kidney failure should not undergo an injection of gadolinium unless this has been cleared by a specialist in this field (renal physician) in order to avoid a potentially life-threatening condition known as NSF (Nephrogenic Systemic Fibrosis). Patients who have had a contrast reaction to the contrast used in CT, IVP, and angiographic examinations are at a 3.7 times increased risk of an adverse reaction. Otherwise, there is no way of predicting who will be allergic to contrast until the dye is given. A patient who becomes allergic will usually develop their symptoms within 10 minutes. It has been shown that gadolinium agents can be retained in areas of the body, such as the brain, or in bone. The importance of this is unclear, and no disease process has been associated, even in cases where deposits have been found. The lowest retention has been shown with the type of agents (macrocyclic) used at all of our clinics. If after reading this information you are not willing to undergo a study with IV contrast, the test may still be done without it; however, in certain cases this will limit the amount of information we can get from the test. The risks associated with the use of gadolinium-based contrast has been explained to me, and I have been given the opportunity to address my questions or concerns.

Consent*

I CONSENT to the administration of a gadolinium-based contrast for the completion of an MRI and/or MRA Study.

I DECLINE to have the MRI and/or MRA with contrast

Signature:*

Date of Service:

No referral or order needed! SELF-REFERRED Mammograms Now Available!

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