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Safety Screening Form

Magnetic Resonance (MR) Procedures

If you prefer, you can download the Safety Screening Form and return the physical copy via email, fax, or call us for other options.

Prior to your appointment please have reviewed the MRI Appointment Instructions.

Please indicate if you have any of the following implanted devices in your body.

If you answer yes to any of the above questions please stop and talk directly with an MRI Coordinator by calling 240-313-9700 option 3. If all answers are No please proceed.

Please answer the following questions. If uncertain of any answer below, please note in the additional comments section at the end of the form to discuss with the MRI coordinator when you are called to review and schedule.

IF YES, please contact your ordering provider for medication

IF YES, please contact your ordering provider to inform them you will need a Medrol Prep for this MRI

Females Only

Please indicate if you CURRENTLY HAVE or HAVE EVER HAD any of the following:

Surgically implanted medical devices
Removable medical devices
If yes, date “pill cam” was ingested

The following items MUST be removed before entering the MRI Room:

  • Body piercings and Jewelry
  • Wigs, hair implants and hair accessories (e.g., bobby pins, barrettes, clips, extensions, weaves)
  • Magnetic cosmetics and hair care (e.g., magnetic eyelashes, magnetic nail polish)
  • Electronic monitoring or tagging equipment (e.g., ankle monitor)
  • Fitness tracker/biomonitor (e.g., Fitbit)
  • Metal-containing clothing material and/or underwear
    • NOTE shiny threads in clothing contain metal

Tattoos or tattooed eyeliner may contain metal that could heat up during the MRI Scan.