An MRI (Magnetic Resonance Imaging) is a medical imaging technique that creates detailed pictures of the inside of the body. It uses strong magnets, radio waves, and a computer to produce images of organs, tissues, and structures within the body—without using radiation as used in X-rays or CT scans.

Your doctor has recommended an MRI, which may require the injection of a radiologic contrast agent, Gadolinium, which, depending on your clinical history, is administered at the Radiologist's discretion. Gadolinium is an approved colorless contrast agent that helps to provide a clearer picture of the body's organs and tissues. Gadolinium is approved for use for both MRI and MRA procedures. Most of the contrast will be eliminated from the body within 24 hours through the urinary system. Even patients with abnormal renal function can safely receive the Gadolinium injection that is typically used in our facility (Dotarem or Gadovist). Patients with severe renal disease should, however, indicate this to a member of our team. You will be asked to give your consent to receive the contrast agent if it is needed (see page 3).

General History

Kindly indicate your responses by ticking the appropriate box

To be completed by female patients:

Metallic Object Declaration and MRI Safety Warning

IMPORTANT WARNING: Certain implants, devices, or objects may be hazardous to you and/or may interfere with the MR procedure (i.e., MRI, MR angiography, functional MRI, MR spectroscopy).

DO NOT ENTER the MR system room or MR environment if you have any questions or concern regarding an implant, device, or object. Consult the MRI Technologist or Radiologist BEFORE entering the MR system room. The MR system magnet is ALWAYS on. Before entering the MR environment or MR system room, you MUST remove all metallic objects including but not limited to  hearing aids, dentures, partial plates, keys, beeper, cell   phone, eyeglasses, hair pins, barrettes, jewelry, body   piercing jewelry, watch, safety pins, paperclips, money   clip, credit cards, bank cards, magnetic strip cards,   coins, pens, pocket knife, nail clipper, tools, clothing   with metal fasteners, & clothing with metallic threads.

Please indicate if you have any of the following:

Please indicate if the following applies to you:

WAIVER & CONSENT FOR ADMINISTRATION OF GADOLINIUM MRI CONTRAST AGENTS

The contrast is injected into the bloodstream using a small needle. During administration, the patient may feel a cool sensation in the arm. If you are breastfeeding, it is safe to resume 12 to 24 hours after contrast administration. An MRI without contrast is an alternative. Please tell a member of staff if you do not wish to proceed with the contrast injection or if you would like to consult your referring doctor regarding the possible risks before deciding.

Risks of Gadolinium MRI Contrast Agents

• Hives
• Itching
• Nausea
• Headaches
• Dizziness
• Abdominal pain
• Extravasation – This happens when some of the contrast agent leaks outside the vein. This may cause swelling and discomfort. Treatment typically includes elevating the arm, applying a cold or warm compress and taking over the counter painkillers.
• Claustrophobia or discomfort from lying in the MRI scanner for an extended period
• Loud noises from the machine may require ear protection
• Heating or movement of metal implants (such as pacemakers, cochlear implants, or metal fragments), which is why it's important to inform staff about any implants before the scan
• Very rare risk of Nephrogenic Systemic Fibrosis (NSF) in patients with severe kidney problems who receive Gadolinium-based contrast agents

If you have previously had a reaction to an MRI contrast injection (Gadolinium), please inform a member of staff. If you are breastfeeding, it is safe to resume 12 to 24 hours after contrast administration. An MRI without contrast is an alternative. Please tell a member of staff if you do not wish to proceed with the contrast injection or if you would like to consult your referring doctor regarding the possible risks before deciding.

By confirming this form, I further assure that:

• I am 18 years of age or older or otherwise authorized to consent.
• I have read and understood the information provided.
• I am not pregnant, or if I am, I have sought medical advice regarding the effects of the contrast.
• I acknowledge that medicine is not an exact science and that no guarantees have been made regarding the effects of the contrast agent.

Witness Confirmation

By clicking the "Confirm" button, you acknowledge that Apex Radiology has electronically witnessed this consent form. The date and time of submission are recorded and securely stored as part of your medical record.