MRI and IV Contrast History and Screening Form

Fill out the form online or bring a printed copy to your appointment—whichever is easiest for you.

1Patient Information

2Magnetic Resonance Imaging (MRI) Consent Form

3Visitor Screening Questionnaire

Patient Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

Sex(Required)

Yes

Height(Required)

Weight (lbs)(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Referring Physician(Required)

Email Address(Required)

Mobile phone number(Required)

Are you pregnant(Required)

Yes

Last Menstrual Period(Required)

Reason you are here today(Required)

Explain your medical problem in detail. (What happened? Where did it happen? How long have you had this problem?)(Required)

Do you have pain?(Required)

Yes

Where?(Required)

Have you had any surgeries in the area(s) that are being imaged today?(Required)

Yes

Where?(Required)

Have you taken any medication/sedation/alcohol today to help you relax for this procedure?(Required)

Yes

If yes, please list(Required)

Time Taken(Required)

Have you had a previous exam related to this problem?(Required)

Yes

If yes, explain(Required)

Do you have any of the following?

Heart Surgery/Heart Valve)

Brain Surgery/Brain Aneurysm Clips

Shunts/Stents/Intravascular Coil

Eye Surgery/Implants

Injury to eye involving metal or metal shavings

Penile Prosthesis

Orthopedic Pins/Rods/Screws/Plates/etc.

Neurostimulator/Biostimulator

Radiation Therapy/Chemo Therapy

History of Cancer or Tumor

Surgery on spine (Neck or Back)

Hearing Aids/Ear Surgery/Cochlear Implants

Vascular Access Ports

IUD/Diaphragm/Pessary

Metal/Mesh Implants/Wire Sutures/ Staples/Internal Electrodes Any type of Electrical/Magnetic/Mechanical Implants in your body

Implanted Cardiac Pacemaker or Defibrillator

Pacing Wires/Swan-Ganz Catheter

Are you pregnant? Last Menstrual Period

Tattoos/Permanent Make-up/ Body Piercings, Hair Extensions

Dentures/Partials/Dental Implants Gunshot Wounds/ Shrapnel/ BB’s Seizures/Headaches/Dizziness

Asthma/Allergic Respiratory Disease

Blood disorder/ Sickle Cell Anemia Are you breast feeding at this time?

Have you ever had a reaction to MRI contrast in the past?

Stroke

Kidney Disease

Liver Disorder

Please explain for each "yes" above(Required)

List any drug allergies(Required)

List all surgeries in your lifetime(Required)

List all medications you are currently taking(Required)

List all locations of your pain or symptoms on your body(Required)

List all locations of any metal in your body(Required)

(Required)

Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that at this time I am pregnant OR NOT pregnant.

Patient/Parent/Legal Guardian Signature(Required)

Date(Required)

Magnetic Resonance Imaging (MRI) Consent Form

You have the right to be informed about the recommended diagnostic procedure to be used, so that you may make the decision whether or not to undergo this procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you can choose to give or withhold your consent to the procedure. If you are pregnant or think you may be pregnant, please inform center personnel at once. It is very important that you inform the technologist if you have a heart valve, a pacemaker, aneurysm clips, or other implanted metal or electrical devices. Your physician has requested a magnetic resonance imaging (MRI) examination to obtain additional information. MRI uses a magnetic field and radio waves to produce images of the body part being examined. MRI does not use x-rays or radiation and is painless. Some scanners may produce loud repetitive noises throughout the procedure therefore, headphones or earplugs will be provided. A contrast may be injected as part of your MRI to provide better images of the part of the body being examined. Potential Risks: The following complications are possible anytime an injection is given: potential for pain, bleeding, bruising or swelling at the injection site. MRI exams requiring contrast may result in: mild headache, nausea, itching or other vague symptoms for a short time after the injection. Additional allergic reactions in response to the contrast agent may include: hives, shortness of breath or difficulty in swallowing. There have been rare instances of death after the administration of the contrast agent. It is very important that you inform the technologist if you experience any of the conditions mentioned in this form. If you have previously had a reaction to a contrast injection such as hives, shortness of breath, any significant reaction requiring hospitalization, a history of asthma or other allergic conditions, any history of anemia, sickle cell anemia or kidney disorder; or if you are breastfeeding you must inform the technologist. The safety of contrast in children under 2 has not been established. The diagnostic test being performed was ordered by your physician based on your symptoms and condition. The benefits of this exam are to assist your physician with a diagnosis. In conjunction with the American College of Radiology (ACR) guidelines, it is the policy of One Step Diagnostic to identify patients at risk of developing Nephrogenic Systemic Fibrosis (NSF) prior to any Gadolinium-Based Contrast Agent (GBCA) injection. The method used to identify such patients require assessing renal function at the time of service. Using a point of service device, a serum creatinine level is acquired and used to calculate the current estimated Glomerular Filtration Rate (eGFR). If provided, you and/or your insurance company will be billed for this service.

(Required)

I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ IT, OR HAVE HAD IT READ TO ME (US), THAT THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS. I (WE) HAVE SUFFICIENT INFORMATION REGARDING THE PROCEDURE(S) AND THE RISKS AND HAZARDS INVOLVED.

Patient Name Printed(Required)

Patient Signature

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

Minutes

AM/PM

Witness Name Printed(Required)

Witness Signature(Required)

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

Minutes

AM/PM

Claustrophobic: Y or N(Required)

Diabetic: Y or N(Required)

HBP: Y or N(Required)

Allergic to Iodine: Y or N(Required)

Allegergies: Y or N(Required)

Surgery(Required)

Pregnant/Breastfeeding: Y or N(Required)

Pacemaker/Metal /Implants/Pain Pumps/Neurostimulator/Stents:(Required)

Kidney Problems: Y or N(Required)

Does PT have an implant card? Y or N(Required)

Visitor Screening Questionnaire

Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N(Required)

Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N(Required)

Within the past 14 days, I have been sick with a cold or flu: Y or N(Required)

Within the past 7 days, I have had a fever: Y or N(Required)

Within the last 7 days, I have had nausea and vomiting and/or loss of taste and /or smell: Y or N(Required)

Within the last 7 days, I have had diarrhea: Y or N(Required)

I now have symptoms of a cold or flu: Y or N(Required)

I now have a fever: Y or N(Required)

Within the past 14 days, I have been around people who have been or are sick with colds or flu: Y or N(Required)

I have been nauseated or have vomited or had diarrhea within the past week: Y or N(Required)

I have received the COVID-19 Vaccination: Y or N- If yes, please indicate which arm.(Required)

Identification Card: Please upload your picture ID card.(Required)

Max. file size: 128 MB.

MRI and IV Contrast History and Screening Form

Patient Information

Magnetic Resonance Imaging (MRI) Consent Form

Visitor Screening Questionnaire

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