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The Consent Form

Magnetic Resonance Imaging is a way of looking inside the body using radio waves, a large magnet and a computer. There are no X-rays involved. As this is a very large magnet, it is very important that you complete this questionnaire carefully. This will let the Radiographer know of any metal on or in your body, which may be a danger to you, or someone else, when entering the scanning room

please submitted twice

PLEASE ANSWER THE FOLLOWING QUESTIONS
Q1: Do you have a cardiac pacemaker or surgery on your heart?
Q3: Do you have any eye, ear or breast implants?
Q5: Do you have, or have you had any metal fragments in any other part of your body, e.g. shrapnel, bullet, belly-ring etc?
Q7: Do you suffer with epilepsy?
Q2: Have you ever had any surgery to your head or back?
Q4: Have you had any metal fragments in your eyes, or have you ever worked with metal?
Q6: Could you be claustrophobic?
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Q7: Do you suffer with epilepsy?
Q8: Do you suffer with diabetes or renal dysfunction?
Q9: Do you suffer from any allergies?
Q10: Could you be pregnant or are you breast -feeding?
Q11: Have you had a previous MRI scan?

Please write below which of the following items apply to you :

 

  1. Aortic or vascular or aneurysm clips

  2. Implanted drug pump

  3. Artificial heart valve

  4. Neurostimulators

  5. Artificial eye or limb

  6. Permanent cosmetic eye lining or tattoos

  7. Bone or joint replacement

  8. Penile Implant Metal rods, plates or pins

  9. Wire mesh, wire sutures or staples

  10. Dentures or partial plates

  11. Implanted cardiac defibrillator

  12. Carotid clips

  13. Any type of coil, filter or stent

  14. Cochlear or ear Implants

  15. Eyelid spring

  16. Electronic monitoring device

  17. Medication patch

  18. Harrington rods IV access port

  19. Hearing aids Shunt

  20. Body Piercing

  21. Other implanted item in body

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Thanks for submitting!

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