MRI HISTORY AND SCREENING FORM

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MaleFemale


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WorkMotor Vehicle AccidentOther

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Do you have or have you ever had any of the following?

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YesNoWhere:

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YesNoLevel:

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If you wear Habitrol and/or Transderm Scop patches they must be removed before you enter the MRI room. No exceptions.


MRI Contrast History:

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YesNo If yes, explain:

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I attest that the above information is correct to the best of my knowledge. I have also informed the technologist that I am not pregnant at this time and I give consent to have a contrast agent administered to me if needed for proper diagnosis of my procedure. I acknowledge that I am aware of the possibility of side effects with contrast and I have had the opportunity to ask questions related to this form, to ask questions regarding the MRI procedure, and I understand the information presented to me.



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