Patient Information
Questions
Please answer these carefully. The following items may be hazardous or may interfere with the MRI examination by producing an artifact. Please indicate if you have the following:
(i.e. Cianturco coil, Gunter IVC Filter, Palmaz stent, etc.)
(i.e. pins, nails, clips, plates, wire, etc)
(attn: welders, machinists, metal workers, etc.)
(i.e. dentures)
Other
Digital Signature
I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.