Dr. Cantrell Medical Information Sheet

MRI Screening Form
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Appointment

:HourMinutesAM/PM Option
Physician
Age
Weight
Height
Body Part
History 1

Please indicate if you have any of the following in your body
*Please call 214-222-6662 if you select yes to any questions in this History 1 section.
Programmable Shunt
Pacemaker/Wires
Internal Defibrillator
Cardiac implant device monitor
Stimulator/Wires
Epidural/Swam Ganz Catheter
Tissue Expander
Surgical Clips
Cardiac Stent
Blood Vessel Coil
Aneurysm Coil
Cochlear Implant/Ear Implant
Tracheostomy
IVC Filter
Penile Prosthesis
History 2

Please indicate if you have any of the following in your body
Hearing Aid
IUD
Eye Implants
Bullets, BBs, Pellets
Medication Patch
Nicotine Patch
Artificial Limb
Infusion Pump
History of Facial Injury
Pregnant or Breastfeeding
Date of last menstrual period

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other implanted metal or devices:
Please list all surgeries you have had and their respective dates.
I attest that the above information is correct. I have read and understand the content of this form and had the opprotunity to ask questions regarding the information on this form, for the MRI procedure that is about to be performed.
Name of person completing the form
Relation to the patient

Other
Signature
Should be Empty:

MRI Screening Form