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QUESTIONNAIRE

MRI Safety

Prior to the examination, this form must be completed by the patient or guardian and signed. Some of the following items may be hazardous in the scanner.

"*" indicates required fields

Step 1: Your details

Name*
Email*
Date of Birth*

Step 2: Upload your Referral

Drop files here or
Accepted file types: jpg, png, pdf, heic, Max. file size: 128 MB, Max. files: 5.
    Please ensure you capture the entire Referral form

    Step 3: Have you ever had surgery of your:

    Head*
    Heart*
    Inner Ear*
    Renal Transplant*

    Step 4: Do you have any of the following magnetic, electronic or metallic implants or devices?

    Neural Stimulator*
    Cardiac pacemaker or pacing wires or Cardiac Defibrillator*
    Ear lmplants*
    Neural Stimulator*
    Eye Implants*
    Stents/Heart Valves*
    Bowel Clips(any recent bowel surgery?)*
    Tissue Expanders (Breast or Penile)*
    Hearing aid (to be removed before scan)*
    Dentures (to be removed before scan)*
    Magnetically implanted dental devices*
    Any other magnetic, electronic or metallic implants or devices*

    Step 5: Do you have any of the following?

    Do you wear any medication patches?*
    Have you ever had metal fragments in your eyes?*
    Do you have any tattoos less than 4 weeks old (including cosmetic)*
    Are you a diabetic?*
    Have you had a recent blood test for kidney function?*
    Are you pregnant or breastfeeding?*
    Have you ever had an allergic reaction to MRI contrast?*
    Do you suffer from claustrophobia?*
    Have you ever had an MRI scan before?*
    Confirmation*
    Permission to contact*