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History and Consent Form - MRI Exam ENGLISH

History and Consent Form - MRI Exam ENGLISH 2026

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The document is a consent form for MRI imaging and contrast administration during pregnancy. It outlines the necessity of the procedure, the technique involved, potential risks associated with MRI and contrast media use in pregnant patients, and emphasizes that while MRI is generally considered safe, uncertainties remain regarding its effects on unborn babies. The patient acknowledges understanding these risks and agrees to proceed with the examination.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Patient Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for identification.
In the 'Procedure to be Performed' section, clearly specify the MRI examination you are consenting to. This helps clarify the purpose of the procedure.
Read through the 'Technique of Procedure' and 'Risk(s) of Procedure' sections carefully. Understanding these details is essential for informed consent.
If applicable, review the 'Use of Contrast Media During Pregnancy' section. Make sure you understand any potential risks associated with contrast media.
Sign and date the form in the Patient Signature and Guardian Signature areas if necessary. This confirms your consent to proceed with the MRI examination.
Finally, ensure that a copy of this signed consent form is saved or printed for your records.

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2018	4.8 Satisfied (28 Votes)

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What is the MRI consent form?

This form is meant to provide you with information about the procedures and risks associated with MRI scanning and to obtain your consent to participate.

Can I wear undergarments during MRI?

Clothing During MRI It is possible to wear your own clothing during a scan if you confirm that they consist of 100% plant-based fabrics (e.g., cotton, bamboo, , etc.) and/or are metal/MRI-safe; elastic/spandex in undergarments, waistbands and cuffs are permissible if they are metal-free.

Do you need written consent for an MRI?

If the patient undergoes the CT/MRI after having read the information sheet without asking for the radiologist, consent is implied. Private practices often play it safer by asking the patient to sign at the end of the information sheet while returning it back for legal documentation.

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What does history mean on an MRI?

History/Reason for exam This section usually lists the information that your ordering provider has listed for the radiologist when they ordered your exam. It allows your ordering provider to explain what symptoms you are having and why they are ordering the radiology test.

Do you have to take your off for an MRI?

Wear clothes that you will be comfortable in for long periods of time T-shirts, sweatpants, jeans, pajamas, or longer dresses (as you will be lying down) Bring socks if you need to remove your shoes (it will be cold in the room!)

History and Consent Form - MRI Exam ENGLISH 2026

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