Magnetic Resonance (Mr) Procedure Patient Screening Form Page 2
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2Certain implants, devices, or objects may be hazardous to you and/or may
WARNING!
interfere with the MR procedure (i.e., MRI, MR angiography, functional
MRI, MR Spectroscopy).
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.
Please indicate if you have any of the following:
YES
NO
Aneurysm Clip(s)
Cardiac Pacemaker
Implanted Cardioverter Defibrullator (ICD)
Electronic Implant or Device
Magnetically Activated Implant or Device
Neurostimulation System
Spinal Cord Stimulator
Internal Electrodes or Wires
Bone Growth / Bone Fusion Stimulator
Cochlear, Otologic, or Other Ear Implant
Insulin or Other Infusion Pump
Implanted Drug Infusion Device
Any Type of Prosthesis (Eye, Penile, Etc.)
Heart Valve Prosthesis
Eyelid Spring or Wire
Artificial or Prosthetic Limb
Metallic stent, Filter or Coil
Shunt (Spinal or Intraventricular)
Vascular Access Port and/or Catheter
Radiation Seeds or Implants
Swan-Ganz or Thermodilution Catheter
Medication Patch (Nicotine, Nitroglycerine)
Any Metallic Fragment or Foreign Body
Wire Mesh Implant
Tissue Expander (e.g., Breast)
Surgical Staples, Clips, or Metallic Sutures
Joint Replacement (Hip, Knee, Etc.)
Bone/Joint Pin, Screw, Nail, Wire, Plate, Etc.
IUD, Diaphragm, or Pessary
Dentures or Partial Plates
Tattoo or Permanent Makeup
Body Piercing Jewelry
Hearing Aid (Remove Before Entering MR System Room)
Other Implant ___________________________________
Breathing Problem or Motion Disorder
Claustrophobia
I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form and
had the opportunity to ask questions regarding the information on this form and regarding the MR procedure that I am about to
undergo.
Signature of Person Completing Form: ________________________________________________ Date: ____/____/____
Form Information Reviewed By: _____________________________ Signature: _________________________________
MRI Technologist
Radiologist
Other: _______________________________
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