MRI Safety Screening Form

REQUIRED for all MRI and Open MRI patients. Must be completed before entering the MRI scan room.

Required — MRI Patients

⚠️ Important Safety Notice: The MRI scanner uses an extremely strong magnetic field. Metal implants, electronic devices, and certain materials can be dangerous or damaged in the MRI environment. Answer all questions honestly and completely. If you are unsure, please tell our technologist — we will verify safety before proceeding.

1. Patient Information

Full Name *

Date of Birth *

Weight (lbs)

Height

Exam Ordered *

2. Implants, Devices & Foreign Objects

Have you ever had surgery, an injury, or a procedure that left any of the following in your body? Check YES or NO for each item.

If you answered YES to any of the above, please describe:

3. Metal Exposure History

Have you ever had a metallic foreign body (e.g., shrapnel, bullet, BBs, metal fragments) in your eye, face, or body?

Yes No

Have you ever worked with metal (e.g., welding, grinding, metalworking) without proper eye protection?

Yes No

Have you ever been told you cannot have an MRI?

Yes No

Have you had a previous MRI? Any adverse reactions?

Yes No

Details (if any YES above):

4. For Female Patients

Are you pregnant or could you possibly be pregnant?

Yes No Unsure

Are you breastfeeding?

Yes No Unsure

If you are pregnant or unsure, please notify our staff immediately. MRI without contrast is generally considered safe in pregnancy, but we will discuss with your referring physician.

5. Comfort & Claustrophobia

Do you experience anxiety or claustrophobia in enclosed spaces?

Yes No

If yes, please let us know when scheduling — we offer an Open MRI option and can recommend options to help you remain comfortable during your scan.

6. Certification & Signature

I have answered all of the above questions truthfully and to the best of my knowledge. I understand that it is my responsibility to inform the MRI technologist of any metallic implants or foreign bodies that may be present in my body. I understand that providing inaccurate information could result in injury or death.

Patient / Guardian Signature *

Sign above

Date *

For Staff Use Only

Technologist Name

Cleared for MRI?

Yes No Conditional

Date/Time

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