Get the free MRI HISTORY and CONSENT FORM - Valley Radiology Imaging

Facility: MRI HISTORY and CONSENT FORM Page 1 FORM.POL.002 Effective Date: July11, 2013 Patients Name: Date of Exam: Body Part to be Examined: Reason for MRI: Referring Dr.: Dr. Phone #: Medical Record

How to fill out mri history and consent

Who needs MRI history and consent?

Patients who are scheduled to undergo an MRI scan need to fill out the MRI history and consent form. This includes those who are referred by their physicians for diagnostic purposes, as well as individuals participating in research studies involving MRI imaging. The form ensures that patients provide accurate information regarding their medical history, potential contraindications, and any known allergies or adverse reactions to contrast agents used during the procedure.

How to fill out MRI history and consent:

1. Start by carefully reading the form: Before filling out the MRI history and consent form, take some time to thoroughly review it. This will help you understand what information is required and why it is important.
2. Personal information: Begin by writing your full name, date of birth, contact information, and any other details requested regarding your identification. Ensure that all personal information is accurate to prevent any confusion or mix-ups.
3. Medical history: The next section will typically ask for your medical history. It is crucial to provide accurate and detailed information about any previous surgeries, existing medical conditions, medications you are currently taking, allergies, and any implanted devices or metallic objects in your body. This information helps the healthcare professionals better understand your health status and determine the safety and appropriateness of undergoing an MRI procedure.
4. Contraindications: Mention if you have any conditions or circumstances that may contraindicate the use of MRI, such as pregnancy, claustrophobia, severe anxiety, or any metal implants that may be adversely affected by the strong magnetic field. It is important to disclose these details to the healthcare provider to ensure they can take the necessary precautions or provide alternative imaging options if needed.
5. Allergies: Indicate any known allergies you have, particularly to contrast agents commonly used in MRI scans. These contrast agents, such as gadolinium-based dyes, may be administered to enhance the visibility of certain tissues or structures during the scan. If you have a history of allergic reactions to these substances, healthcare professionals may consider alternative imaging techniques or use alternative contrast agents.
6. Informed consent: The last part of the form generally includes a section for obtaining your informed consent. It explains the relevant risks, benefits, and alternatives associated with undergoing an MRI scan. Read through this section carefully to understand the details of the procedure and its potential implications. If you have any questions or concerns, do not hesitate to seek clarification from the healthcare provider.
7. Signature and date: Once you have completed filling out all the necessary information, sign and date the consent form to express your understanding, agreement, and compliance.

Remember, if at any point you are uncertain about how to complete the MRI history and consent form or have any concerns, do not hesitate to ask for assistance from the healthcare provider or staff responsible for overseeing the procedure. Ensuring accurate and complete information on the form helps the healthcare team provide the best possible care during your MRI scan.

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What is mri history and consent?

MRI history and consent is a form that patients need to fill out before undergoing an MRI scan. It typically includes questions about the patient's past medical history and any allergies or conditions that may affect the scan.

Who is required to file mri history and consent?

Any patient who is scheduled to undergo an MRI scan is required to fill out the MRI history and consent form.

How to fill out mri history and consent?

Patients can fill out the MRI history and consent form either by hand or electronically, depending on the facilities' procedures. They must provide accurate and complete information to ensure a safe scan.

What is the purpose of mri history and consent?

The purpose of the MRI history and consent form is to gather information about the patient's medical history, which can help healthcare providers tailor the scan to the patient's needs and ensure safety during the procedure.

What information must be reported on mri history and consent?

The MRI history and consent form typically ask for information about the patient's medical history, allergies, current medications, and any conditions that may affect the MRI scan.