Patient Information

Patient Name *

Date *

Date of Birth *

Height

Weight

Sex

MRI Safety Screening

The following items may be hazardous or may interfere with the MRI examination. Please indicate whether you have or have ever had any of the following.

Cardiac pacemaker * Yes No

Implanted cardiac defibrillator * Yes No

Aneurysm clip(s) * Yes No

Carotid artery vascular clamp * Yes No

Neurostimulator * Yes No

Insulin or infusion pump * Yes No

Implanted drug infusion device * Yes No

Bone growth/fusion stimulator * Yes No

Cochlear, otologic, or ear implant * Yes No

Any type of prosthesis (eye, penile, etc.) * Yes No

Artificial limb or joint * Yes No

Electrodes (on body, head or brain) * Yes No

Intravascular stents, filters or coils * Yes No

Shunt (spinal or intraventricular) * Yes No

Swan-Ganz catheter * Yes No

Any implant held in place by a magnet * Yes No

Transdermal delivery system (Nitro) * Yes No

IUD or diaphragm * Yes No

Tattooed makeup (eyeliner, lips, etc.) * Yes No

Body piercing(s) (Remove before MRI) * Yes No

Any metal fragments * Yes No

Internal pacing wires * Yes No

Metal or wire mesh implants * Yes No

Hearing aid (Remove before MRI) * Yes No

Dentures, braces, permanent retainers, or other dental implant * Yes No

Claustrophobia * Yes No

Pregnancy or breastfeeding * Yes No

Patient Access to images and reports

First look MRI is the imaging center that will perform the MRI requested by your physician and/or attorney. Texas diagnostic Radiology controls the images, reports, billing, and payments. You will sign a letter or protection today for Texas diagnostic Radiology.

Direct all medical records requests or billing inquiries to Texas Diagnostic Radiology at 214-831-6640.

Signature & Submission

I attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and have had the opportunity to ask questions. I have also informed the technologist whether I am pregnant or may be pregnant.

I confirm that the information above is accurate and complete to the best of my knowledge. *

Patient / Parent / Legal Guardian Signature — Type Full Name *

Texas Diagnostic Radiology Screening Form