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MRI QUESTIONNAIRE FORM

MRI QUESTIONNAIRE FORM 2026

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The document is an MRI Questionnaire Form that patients must complete prior to their MRI visit. It collects essential information about the patient's symptoms, medical history, previous examinations, allergies, and any implants or conditions that may affect the MRI procedure. The form emphasizes the importance of disclosing specific health details to ensure patient safety during the examination.

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Click ‘Get Form’ to open the MRI QUESTIONNAIRE FORM in the editor.
Begin by entering your PATIENT NAME, OCCUPATION, AGE, and DATE at the top of the form. Ensure all information is accurate for a smooth process.
In the REF. Dr. section, write down the name of your referring doctor to maintain clear communication regarding your care.
For section A, describe any symptoms that led to your MRI request. Use clear and concise language to ensure understanding.
Answer the questions regarding previous x-rays, operations, allergies, and any blood cell abnormalities by selecting 'Yes' or 'No' as applicable.
Carefully review the list of medical history questions. Mark 'Yes' or 'No' for each item and provide additional details where necessary.
Finally, complete the section on how you heard about Rye Radiology MRI and sign at the bottom of the form before submission.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (80 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I order an MRI on my own?

You dont need a referral from a medical professional to get scanned with us. Instead, youre in control: search for a private MRI scanner near you, book online, and well take care of the rest. After your scan, we share your MRI scan results digitally.

What is an MRI safety questionnaire?

The MRI questionnaire is designed to identify all potential implants and/or foreign bodies that the patient has.

What do they ask you before an MRI?

You will typically be asked to change into a gown and to remove things that might affect the magnetic imaging, such as: Jewelry. Hairpins. Eyeglasses. Watches. Wigs. Dentures. Hearing aids. Underwire bras.

Can I just ask for an MRI?

While it is possible to get an MRI without a referral, medical referrals are important because your insurance may deny coverage without one, and diagnostic imaging can be expensive if youre paying out-of-pocket.

Can you get an MRI without a doctors request?

Yes, getting an MRI scan without a doctors referral is possible. While your doctor is your primary care provider, you can stay in control of your health care by eating healthy, exercising, and keeping up with your annual health screenings.

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What disqualifies you from getting an MRI?

you think you have any metal in or on your body. youre pregnant or breastfeeding. youve ever had an allergic reaction to a contrast agent. you have kidney problems.

How can I get an MRI without a referral?

Can I Get an MRI Without a Referral? The best way to get an MRI scan without a doctors referral is to schedule a private screening at a private screening clinic (also known as a free-standing radiology clinic).

MRI QUESTIONNAIRE FORM 2026

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