MRI Safety Questionnaire

Patient Details

Please list the number we can most easily contact you on

Booking Details


Medical History

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

Safety Information

Do you have or have you had:

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:

Contrast Dye

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

Next Appointment with your Doctor

Release of Medical Information

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.

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

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

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.


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.

Your browser does not support the Signature field