MRI Safety Questionnaire MRI SAFETY QUESTIONNAIREPrior to the examination, this form must be completed by the patient or guardian and signed. Some of the following items may be hazardous in the scanner.TitleMrMrsMsMiss Your First Name (required) Your surname (required) Your Email (required) Your Date of birth Referral upload*(Click "Choose File" button below to attach or take a photo of your referral for upload): Please ensure you capture the entire referral form.Have you ever had surgery of your:Head YesNoHeart YesNoInner Ear YesNoInner Ear YesNoRenal Transplant YesNoDo you have any of the following?Neural Stimulator YesNoCardiac pacemaker or pacing wires or Cardiac Defibrillator YesNoAneurysm clips (surgical clips on arteries in your brain) YesNoEar lmplants YesNoEye Implants YesNoStents/Heart Valves YesNoBowel Clips(any recent bowel surgery?) YesNoTissue Expanders (Breast or Penile) YesNoHearing aid (to be removed before scan) YesNoDentures (to be removed before scan) YesNoMagnetically implanted dental devices YesNoAny other magnetic, electronic or metallic implants or devices YesNoIf yes, please list: Do you wear any medication patches?YesNoHave you ever had metal fragments in your eyes?YesNoDo you have any tattoos less than 4 weeks old (including cosmetic)YesNoAre you a diabetic? YesNoHave you had a recent blood test for kidney function? YesNoAre you pregnant or breastfeeding? YesNoHave you ever had an allergic reaction to MRI contrast? YesNoDo you suffer from claustrophobia? YesNoHave you ever had an MRI scan before?YesNoIf yes;WhereWhen Who has the images? I the patient or substitute decision maker, confirm that I have read and/or been read and understand these questions and have answered them correctly. [anr_nocaptcha g-recaptcha-response]