MRI SAFETY SCREENING FORM

Circle or underline MRI risk considerations: Heart valve, pacemaker, or defibrillator. Brain aneurysm clip or coils. Stents. Eye implants. Neurostimulator. Cochlear implant. Hearing aide. Vascular access port. Metal mesh, wire sutures, staples, internal electrode. Infusion drug pump. Tattoo’s or body piercing. Dentures. gunshot wounds or BB’s ................
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