MRI Scan Patient Consent Form

Patient Information

Full Name Date of Birth Patient ID / Reference Number

Information & Risks

I acknowledge that I have been informed about the purpose, procedure, and possible risks or discomforts of the MRI scan. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Medical Screening

I do not have a pacemaker or other implanted electronic device. I do not have any metal fragments, implants, or devices in my body. I have informed my doctor if I have issues with claustrophobia.

Consent

I voluntarily consent to undergo the MRI scan and authorize the healthcare team to perform the procedure.

Patient Signature Date

Witness (if required) Date