1
Screening
2
Privacy
3
Consent
4
Release
✓
Sign & Submit

Patient Information

Please complete all fields before continuing

Full Name *
Date of Birth *
1

MRI Safety Screening

Answer Yes or No for every item — your technologist will review any "Yes" answers with you

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 *
Implanted cardiac defibrillator *
Aneurysm clip(s) *
Carotid artery vascular clamp *
Neurostimulator *
Insulin or infusion pump *
Implanted drug infusion device *
Bone growth/fusion stimulator *
Cochlear, otologic, or ear implant *
Any type of prosthesis (eye, penile, etc.) *
Artificial limb or joint *
Electrodes (on body, head or brain) *
Intravascular stents, filters or coils *
Shunt (spinal or intraventricular) *
Swan-Ganz catheter *
Any implant held in place by a magnet *
Transdermal delivery system (Nitro) *
IUD or diaphragm *
Tattooed makeup (eyeliner, lips, etc.) *
Body piercing(s) (Remove before MRI) *
Any metal fragments in eyes *
Internal pacing wires *
Metal or wire mesh implants *
Hearing aid (Remove before MRI) *
Dentures, braces, permanent retainers, or other dental implant *
Claustrophobia *
First trimester of pregnancy*
Please explain any items you answered "Yes"

Many implants and devices are MRI-compatible — answering "Yes" 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 answered "Yes" to 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 a diagnostic imaging center that provides MRI images for Texas Diagnostic Radiology. I understand that:

  • First look MRI performs the MRI(s) requested by your physician and/or attorney.
  • I must follow up with my doctor or Texas diagnostic Radiology for the MRI results.
  • Texas diagnostic Radiology manages the images, reports, billing, and payments. I will sign a letter of protection today for Texas diagnostic Radiology.
  • All medical records requests or billing inquiries should be directed to Texas Diagnostic Radiology at 214-831-6640.

We are 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 from Texas Diagnostic Radiology
  • Request corrections to inaccurate or incomplete information from Texas Diagnostic Radiology
  • Ask us to limit how we use or share your information

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.

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.

I understand that:

  • First Look MRI is not liable for harm from my failure to obtain appropriate follow-up treatment.
  • 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.

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.