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Screening
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Privacy
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Consent
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Release
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Sign & Submit

Patient Information

Please complete all fields before continuing

Full Name *
Date of Birth *
Email Address
Phone Number
1

MRI Safety Screening

Check everything that applies — your technologist will review any checked items with you

Cardiac & Electrical Devices
Implants, Prosthetics & Medical Devices
Personal & Other
Please describe the items you checked above

Many implants and devices are MRI-compatible — checking a box does not automatically prevent your scan. Please provide any details you know (e.g., "left hip replacement, 2019" or "titanium rod in right femur, unsure of brand"). Your technologist will review everything with you before the scan.

Having any of these does not necessarily prevent you from having your MRI. Your technologist will determine what is safe for you.
⚠  You have checked one or more items. Please fill in the details box above so your technologist can review them before your scan.
2

Notice of Privacy Practices

How we protect and use your health information

First Look MRI is required by HIPAA to protect the privacy and security of your health information. As a patient, you have the right to:

  • Access or receive a copy of your medical records
  • Request corrections to inaccurate or incomplete information
  • Ask us to limit how we use or share your information
  • Request that we communicate with you in a specific way or at a specific address

We use your information to provide and manage your care, and as required by law. We will never sell your information or use it for marketing without your written permission.

3

Consent to MRI Procedure

Please read carefully before signing

About MRI: MRI uses magnetic fields and radio waves — no radiation — to create images of internal body structures. You will lie on a padded table that slides gently into the magnet. The procedure is painless. Humming and thumping sounds during the scan are normal.

About First Look MRI: First Look MRI is a diagnostic imaging center, not a treating provider. I understand that:

  • I am solely responsible for sharing my MRI results with my own physicians
  • I may request that First Look MRI send results directly to a provider on my behalf
  • If I ordered this exam without a doctor's referral, it may not be medically necessary
  • First Look MRI is not liable for harm resulting from failure to obtain appropriate follow-up treatment

Payment: Payment is due directly from me at the time of service. First Look MRI does not accept insurance assignment or bill insurance. I am solely responsible for all charges. Whether my insurer reimburses me is my own responsibility.

Valuables: I am advised not to bring valuables to the facility. Jewelry can be sealed in an envelope for security, and it can be taken into the room with you. The practice is not responsible for other lost personal property.

Communications: I consent to receiving appointment reminders and health-related communications via email and/or text at the contact information I have provided.

4

Authorization to Release Information

Optional — your care will not be affected if you decline

We will never share your medical or billing information without your verbal or written authorization.

What to Share on this Appointment
Share With — Provider or Facility Name (leave blank if not authorizing)

Signature & Submission

By signing below I confirm that all information I have provided is accurate, and that I agree to the terms in all four sections above. This single signature applies to the entire form.

Center Location *
Date
Patient Signature — Type Full Name *

By typing your name above you are applying your electronic signature to this form.