H�\��j�0��~ MRI patient Checklist & Consent Name Date of Birth MM DD YYYY MRN HT WT Tech Indications The following may be hazardous or may interfere with the examination by producing an artifact Please remove all jewlery (except wedding band), bobby pins, watches, cell phone, credit cards, hearing aids. Enter all required information in the required fillable fields. Contact the Standards Interpretation Group at (630) 791-5900 for assistance. ¨ Perform the scan and monitor the patient. MR Safe clothing will be provided to you to wear during your MRI scan. For questions, call 425.656.5550. 0000003097 00000 n Select the Correct Scan Parameters for your MRI equipment. 0000042057 00000 n 0000056816 00000 n The chiller may be provided as part of the deal, or you may need to purchase one yourself. 2. 6. Your MRI will take about 45 minutes, so plan on being at the MRI imaging center for around one hour. 0000004177 00000 n 0000063810 00000 n Qualified Medical Physicist/MRI Scientist Date: Patient Transport and Gantry Filming Viewing: MRI Accreditation Program Visual Checklist RF Integrity and Control Room Facility Safety Technologist Initials: Date of Review: Pass = Fail =F It may be provided to the radiologist to support the confirmation of the patient’s MRI scan eligibility. Signature of patient: Date: MRI Scan Patient Checklist: ... For additional instructions, refer to the St. Jude Medical MRI Procedure information document, the Ellipse ICD, Fortify Assura ICD, Durata lead and Optisure lead manuals. Have you had a previous MRI scan? ���+� H�\��n�0��~ /�EEB��VBHi�JY̏&3@�I�@Y�����# �_[߁K��mwC?��g�}����/�5���̲�]����|m��d Checklist with their referring provider or on their own as soon as possible. Patient Prep Checklist Upon arrival, the patient completes all necessary paperwork including the MRI screening form and any relevant consent forms. 3. 0000021596 00000 n 0000028207 00000 n Appendix 3: safety screening form, MR hazard checklist, and patient instructions. clothing and worn/removable items from your body. ���`)���7e'�N��(:Qv��Dى�}~���؉������lp6:���g�����lp6:���g����ؕ�+���y n��0f���.17�r����c6\g�u��7��Ͽ�o�e���P��1n�V4�� �.|�VC?�8g�W� jp � endstream endobj 353 0 obj <> endobj 354 0 obj <>stream 01737 231610. and leave a message, including your full name and contact details. Have an MRI chiller installed with all the necessary connections. The intuitive drag&drop graphical user interface makes it simple to add or relocate areas. About; MRI Checklist; MRI Forms; Patient Resources pr. 0000038482 00000 n If the answer to any of the questions on the MRI Safety Checklist is YES, please call 919 … 0000010391 00000 n 0000079023 00000 n Emory Low Dose CT Lung Screening Order Form: CT: All Emory Healthcare locations: Download PDF (68KB) CT Lung Screening: Shared Decision Making Checklist for Providers: CT: All Emory Healthcare locations: Download PDF (103KB) Emory Breast Imaging Order Form (For all BIC Locations) Mammography, Breast MRI, Breast Ultrasound, Breast Biopsy on . 0000024335 00000 n h�b``�d``�e`c`9� Ȁ ��@Q� �� �g0�'CV��*��W^W�������r8@L�H����Y8g2�),�s �ZŘ���aA8C&�e�%��s�H_x�xȹ���.��� LؕmT3L��p������ǁl-L �/�p0����;{w�\��#O�X���b`�����1��!vL�1��)��Ļ J%= endstream endobj 350 0 obj <>/Metadata 347 0 R/Pages 346 0 R/StructTreeRoot 10 0 R/Type/Catalog/ViewerPreferences<>>> endobj 351 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/Properties<>/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 595.276 841.89]/Type/Page>> endobj 352 0 obj <>stream 0000016461 00000 n 0000014634 00000 n If yes, when was the most recent? 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