About this template
An MRI screening form is an essential evaluation tool used by medical facilities, imaging centers, and hospitals to gather crucial health history and safety data before a patient undergoes a Magnetic Resonance Imaging (MRI) scan. Because MRI machines utilize powerful magnetic fields and radio waves, certain metallic implants, medical devices, or foreign objects can pose severe health risks to the patient or interfere with scan quality.
Traditionally, patients discovered potential contraindications only after arriving at the clinic, leading to wasted time, rescheduled appointments, and frustration. By utilizing this digital MRI screening form template via Doc2Form, medical practices can collect comprehensive patient details—including personal demographics, referring physician information, symptoms, and a detailed implant questionnaire—remotely and securely before the appointment date. This streamlines the clinical workflow, ensures safety protocols are met early, and prepares administrative staff for the procedure without unnecessary delays.
Key features
- Screen for metallic implants and hazardous medical devices remotely
- Collect patient demographics and referring physician details in one step
- Streamline pre-procedure preparation and reduce day-of cancellations
- Standardize medical history intake securely and efficiently
Use cases
Outpatient diagnostic imaging centers checking patients prior to sche…
Outpatient diagnostic imaging centers checking patients prior to scheduled scans
Hospitals streamlining pre-admission intake for radiology departments
Specialty clinics verifying patient eligibility and safety before adv…
Specialty clinics verifying patient eligibility and safety before advanced diagnostic procedures
What this form collects
- Date of Screening (Date)Enter today's date.
- Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Age (Short answer)Enter your current age in years.
- Gender (Multiple choice)Select your gender identity.
- Postmenopausal Status (Multiple choice)Applicable if assigned female at birth.
- Weight (Short answer)Enter your weight in pounds or kilograms (please specify units).
- Height (Short answer)Enter your height.
- Email Address (Short answer)We will use this to send appointment confirmations and prep instructions.
- Phone Number (Short answer)Enter a number where we can reach you quickly if needed.
- Home Address (Paragraph)Enter your residential street address, city, state, and ZIP code.
- Referring Doctor Full Name (Short answer)Enter the name of the physician who ordered this MRI scan.
- Referring Doctor Phone Number (Short answer)Enter your doctor's office phone number.
- Referring Doctor Email (Short answer)Enter your doctor's office email if known.
- Body Part to be Examined (Short answer)Specify the anatomical area ordered for scanning (e.g., lumbar spine, right knee, brain).
- Reason for MRI (Paragraph)Briefly describe your symptoms or the medical reason for this scan.
- Implant & Condition Screening (Checkboxes)Do you have any of the following implanted in your body? Select all that apply.
- Other Implants Explanation (Paragraph)If you have any other metallic fragments, shrapnel, tattoos with metallic ink, or body piercings not listed above, please describe them here.
- Patient Signature (Short answer)Please type your full legal name to confirm that all screening answers are accurate and complete to the best of your knowledge.
- Date Signed (Date)Enter the date of signature.
FAQ
What is an MRI screening form used for?
It is used to identify any potential safety hazards—such as pacemakers, aneurysm clips, surgical staples, or metal fragments—that would make an MRI scan unsafe for the patient.
Why is pre-screening patients important for MRI scans?
Magnetic Resonance Imaging involves strong magnetic fields that can interact dangerously with certain metals and electronic devices. Pre-screening prevents medical emergencies and avoids wasted appointment slots.
Can I customize the questions on this template?
Yes! Once you convert or open this template in Doc2Form, you can easily add, remove, or edit any questions to match your facility's specific screening protocols.
How do patients access this form?
You can share the Google Form link via email or text message with patients after they schedule their appointment, allowing them to fill it out from any device before arriving.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.