MRI SAFETY AND CONSENT FORM, WITH OR WITHOUT CONTRAST
Patient Name Age Weight
NO YES NO YES
Cardiac pacemaker or defibrillator? Internal wires, catheters, electrodes, stents or coils?
Brain surgery for an aneurysm? Ever had metal fragments in or removed from eye?
Kidney problems, surgery, or transplant? Neurostimulators, bone fusion stimulators, or TENS?
Multiple myeloma or lupus? Penile prosthesis?
Severe high blood pressure, even on medication Small bowel endoscopy capsule?
Diabetes requiring medication? Skin patch, decorative tattoos or permanent cosmetics?
Hearing aid or implant? Are you on dialysis?
Bullets or shrapnel? Sickle cell anemia?
Prior reaction to intravenous dye? Latex or drug allergy?
Asthma or multiple allergies?
Implanted hardware of any kind (except dental)? If yes, what type?
For Women of Child-Bearing Age Only:
Any possibility of being pregnant? IUD in place?
Your physician has requested that we perform an MRI scan. An alternative to this procedure may be an ultrasound, x-ray, or CT scan.
However, your physician believes this test to be the best diagnostic test for you. As part of your exam, a contrast agent may be
injected into your vein in order to produce better images of the part of the body being examined. If you wish to refuse the contrast
injection, inform the technologist and the MRI will be conducted without the contrast agent.
The following complications are possible whenever an injection is given. There is a potential for pain, bleeding, and bruising at the
injection site. Allergic reactions in response to the contrast agent may include hives, shortness of breath or difficulty swallowing.
There have been rare instances of death after the administration of a contrast agent.
The contrast agent used in MRI is called gadolinium. This agent is a sterile, clear, colorless solution that will make certain normal and
abnormal structures in the body easier to see. MRI contrast agents often help detect and characterize abnormalities that may not be
seen without their use.
The safety of its use in pregnant women has not yet been determined. If you are breast-feeding, you should pump and discard your
breast milk three times over a 24 hour period following this test. It is safe to resume breast-feeding 24 hours after this test.
If you have previously had a reaction to a contrast injection, have a history of asthma or other allergic conditions, kidney disease
or are currently undergoing dialysis, YOU MUST INFORM THE TECHNOLOGIST. Patients with diminished or absent kidney
function who receive gadolinium, particularly at high doses, are at risk for developing a serious, potentially life-threatening condition
known as nephrogenic systemic fibrosis (NSF).
I (we) certify this form has been fully explained to me, that I (we) have read it or have had it read to me, and that I (we)
understand its contents. I (we) have been given an opportunity to ask questions about my condition, alternative forms of
treatment, the procedures to be used and the risks and hazards involved. I (we) believe that I (we) have sufficient information
to give this informed consent. Having understood this information, I hereby freely give my consent for this MRI examination.
Signature of Patient or Authorized Representative Date
For Clinical Use Only – Contrast Administration
________cc of _______________ contrast injected at ___________ AM/PM Contrast Lot #__________________________
Contrast Reaction or Extravasation (If yes, explain)
___________________________ ______________
Signature of Technologist Date Rev 3/8/11
