Patient Details

First Name

Last Name

Date of Birth

Phone

Please list the number we can most easily contact you on

Height (cm)

Weight (kg)

Booking Details

Do you have an MRI appointment booked with us?

Yes

Branch where your MRI appointment is booked

Branch Email

Appointment Date

Medical History

Have you had a previous MRI, or any related imaging related to this scan?

Yes

Please provide details of when and where

Do you suffer claustrophobia?

Yes

Have you ever had an eye injury caused by metal?

Yes

Has the metal been removed by a doctor?

Yes

Have you had surgery or another procedure in the past 6 weeks?

Yes

Please provide us with as much relevant detail about that surgery:

eg. type of procedure, when, where performed, name of surgeon

Safety Information

Do you have or have you had:

A pacemaker

Yes

An artificial heart valve

Yes

An electrical stimulator

Yes

An implanted or external infusion or drug pump

Yes

A shunt in your brain or spinal cord

Yes

Any coils, filters or stents

Yes

Any mechanically, electronically or magnetically activated implants

Yes

An aneurysm clip

Yes

Any eye or ear surgery

Yes

A gastric band

Yes

Any bullets, shrapnel or other pieces of metal in your body

Yes

An Intra-Uterine Device (IUD)

Yes

Are you pregnant or do you suspect you may be pregnant

Yes

Are you currently breast feeding

Yes

If you have answered yes to one of the above questions, one of our MRI Modality Experts may contact you if we require further information.

Other Devices

Please indicate if you have:

Tattoos or permanent eyeliner

Yes

Any removable dental work, dentures or dental plates

Yes

Hearing aids

Yes

Any metal joints/pins, plates, rods, screws, nails or clips

Yes

Any medicated or metallic backed patches/dressings?

Yes

Any Continuous Glucose Monitor (CGM) or alternative monitoring device?

Yes

Contrast Dye

For some examinations, contrast dye may be used to improve the image of body organs and tissues.

Do you consent to contrast dye being used

Yes

Do you have renal (kidney) failure

Yes

If you have any allergies, please list them

Next Appointment with your Doctor

Do you have an appointment with your doctor to discuss the results of this scan?

Yes

Please provide details of when and where your appointment will be

Release of Medical Information

Have you had any surgical procedure that involved the implantation of a device?

Yes

Surgery Details

An implanted device may need to be researched to check its compatibility with our MRI systems. Please check this box to provide consent for Benson Radiology to request the surgical notes from any relevent procedure to help ensure the safe undertaking of the MRI scan.

I consent to the release of this information to Benson Radiology

Upload Documents

To assist us with your appointment, please upload photos/scans of any relevant information such as your request form (if you have one) or implant card

Have we already received a copy of your request form?

Yes

No / Unsure

Do you have a copy of your request form?

Yes

Upload Document

Only .DOC, .DOCX, .PDF, .RTF, .ZIP, .RAR, .GIF, .PNG and .JPG files (less than 5MB) accepted.

Choose a file

Do you have any other documents to send? ie. Implant card, previous report

Yes

Upload Document

Only .DOC, .DOCX, .PDF, .RTF, .ZIP, .RAR, .GIF, .PNG and .JPG files (less than 5MB) accepted.

Choose a file

Pre Examination Information

It is likely you will be required to change into a gown prior to your examination (although some loose fitting sportswear may be acceptable). Your personal items will be stored securely. Before your scan you must remove all metal objects in your posession or on your body. This includes watches, mobile phones, credit cards, coins, keys, body piercings, earrings, hair clips, hearing aids, dentures, jewellery etc.

Disclaimer

I acknowledge to the best of my understanding that the above answers are true and correct and I consent to the MRI examination. Further, I acknowledge that Benson Radiology has taken reasonable precautions and is not liable for any event that might result from incorrect answers on this form.

I acknowledge the disclaimer

Signature

Patient information

MRI Safety Questionnaire