MRI Safety Form

Your Name:(Required)

First Last

Date of Birth(Required)

Your best Phone contact:

Your email:

External Devices

Any external electronic medical devices must be removed prior to entry into the MRI unit to avoid personal harm and/or damage to the device, including: • External medication delivery devices (e.g. Insulin Pumps) • Continuous Glucose meters (including the sensor) • Hearing aids

Implanted Metallic Objects

Whilst most modern medical implants are acceptable for MRI, some implanted devices may pose a significant safety risk when undergoing MRI. By providing the details of your implanted device a CIG MRI technologist will be able to assess and confirm suitability for scanning. Please indicate below if you have any of the items listed, providing the make and model of the device/implant in the space provided. An MRI technologist will contact you only if deemed unsafe to conduct your scan, or, if further information is required.

Do you have a cardiac pacemaker or implanted defibrillator?

Yes

No

Have you ever suffered a metal injury to the eye?

Yes

No

Please add more information about the metal injury(Required)

Do you have an implant related to Head, Ear, or Heart Surgery?

Yes

No

Please enter the Make:

Please enter the Model:

Please enter the hospital where the surgery was performed:

Name of Surgeon:

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Canberra Imaging Group

MRI Safety Form

MRI Safety Form

External Devices

Implanted Metallic Objects