MRI safety Checklist

MRI is considered one of the safest forms of imaging as there is no radiation, but it does use a very strong magnetic field which is always turned on. Please read the following form and complete all questions carefully

Patient name

DOB *

Weight

Height

MRI contrast administration

For some MRI examinations, contrast dye may be required to improve the imaging of organs and tissues.

Do you consent to contrast dye being used *YesNo

Do you have diabetes? *YesNo

Do you have kidney disease? *YesNo

If you have any allergies, please list them

I acknowledge that to the best of my understanding, the above answers are true and correct:

Name *

Date *

Month

Day

Year

Emergency contact name *

Phone number *

Relationship