MRI Screening

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Body part for MRI scan: (At least one body part must be selected You may select more than one).
 RightLeftBoth
Knee
Shoulder
Arm, upper
Elbow
Arm, Lower
Wrist
Hand
Pelvis
Hip
Leg, upper
Leg, lower
Ankle
Foot
 Yes
Cervical (neck)
Thoracic (mid-back)
Lumbar (lower-back

The MRI machine is an extraordinarily strong magnet. Before you are permitted to enter, we must know if you have metal in your body. Any metal objects can interfere with your scan and can be dangerous, please answer all the following questions carefully. 

Do you have any of the following please answer (Yes or No) *
 YesNo
Pacemaker
Internal Defibrillator
Brain Aneurysm Clip
Programmable Shunt
Non-Programmable Shunt
Intravascular Stents/Coils/Filters
Metal Worker (Welder)
Injury to the eye involving metal
Spinal or Neuro Stimulator
Insulin Pump (Implanted or External)
Implanted Drug Infusion Pump
Carotid Artery Vascular Clamp
Heart Valve Prosthesis
Continuous Glucose Monitor
Flu-like Symptoms
Are you now or could you be pregnant
Artificial Prosthesis (Eye, Limb)
Hearing Aid/WIG
Cochlear or stapes Ear Implant
Eye Lid Springs or Wires
Retinal Tacks or Buckle
Permanent Tattooed Eyeliner
Dentures, Retainers, Braces, Partials
Electronic Ankle Device
Breast Tissue Expander
IUD
Medication Skin Patch
Penile Implant
Claustrophobic
Wheelchair or Walker
IV Iron Infusion (with in last 90 days)
Are you currently breast feeding
Do you have any Allergies? *
Have you had any major surgeries? *
Please list ALL MAJOR surgeries using the boxes below:
In the last three months, have you had an IV Iron Infusion? *
Do you have any history of Tumor, Cancer, or Lymphoma? *
Do you have a history of kidney disease or Renal Failure? *
Will you require sedation to ease claustrophobia / anxiety? *
If Yes, you will require a driver to take you home after your MRI. Please provide the name, address and phone number(s) of your driver. If no sedation is needed, enter N/A into the required boxes below. Note: Your driver must accompany you at check-in prior to administration of sedation.
Is cell phone or home phone preferred? *
If driver does not have a cell phone or home phone please indicate below. *
All the information above is correct to the best of my knowledge. Please sign below (patient or parent/guardian) *
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