Patient Information
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)
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.