MRI Pre-Screening

First Name

Last Name

Date of Birth

Phone Number

Email Address

Date of Scheduled Test

Please answer each of the following questions for your upcoming MRI. If the answer is Yes to any of these questions you will receive a follow up call for more details.

Do you have a pacemaker, defibrillator, or stimulator of any kind?

Yes

No

Do you have any mechanical devices, aneurysm clips, coils, stents or metal fragments in your body?

Yes

No

Have you had any recent surgeries (within past 6-8 weeks)?

Yes

No

Are you claustrophobic?

Yes

No

Are you currently on dialysis?

Yes

No

If yes, have you been prescribed medication for this in the past?

If you have questions for your doctor or nurse, please call the clinic directly at 901-522-7700.