MRI / MEG Consent & Safety Screening Form

ALL individuals are required to fill out this form BEFORE entering the MRI and / or MEG environments.

In order to submit this form your Email Address and Date of Birth must match the data inputted by the referrer.

The MR system has a very strong magnetic field that may be hazardous to individuals entering the MRI environment if they have certain metallic, electronic, magnetic or mechanical implants, devices or objects.

MEG is very sensitive to large magnetic fields and could be damaged if any metal is placed nearby. Be advised, the MRI and MEG Scanner is ALWAYS on!

    Step 1


















    Step 2

    If you answer YES to any of the questions marked with an asterisk * please contact us as soon as possible: IHN Administrators Contact Number: 0121 204 3882 / Email: ihn_admin@aston.ac.uk

    Have you had a previous MRI and / or MEG scan? Any problems?

    Have you had any heart surgery? Do you have a Cardiac Pacemaker / Stent / Heart Valves?

    If yes, type of surgery?

    Have you had ANY surgery on your head, eyes, or ears?

    If yes, how, where, what?

    Have you EVER had any metal fragments or shrapnel in your eyes or anywhere in your body?

    If yes, how, where, what?

    Have you had ANY operations where ANYTHING was left inside your body? E.g. any metal wires, pins, plates, screws or similar?

    Have you had ANY other surgery in the last 3 months?

    Do you have any electrical devices e.g. VNS, hearing aid, cochlear implant, nerve stimulator or implantable pump?

    Do you have a hydrocephalus shunt?

    Is it programmable?

    Do you have any aneurysm clip(s)?

    Are you wearing any wound dressings, joint supports or limb weights?

    Are you wearing a medicinal patch e.g. HRT, nicotine, or pain relief? (Please remove prior to MRI scan)

    Have you ever had a fit / blackout or suffered from epilepsy?

    Have you had any recent tattoos, permanent make-up or body piercings?

    Have you had any metal dental work other than simple fillings e.g. non-removable dentures or braces, crowns or bridgework?

    Do you have an IUCD / Coil in place or sterilisation clips?

    Is there any possibility of you being pregnant?

    Please remove ALL metal objects from your person (keys, coins, hearing aids, watches, mobile phones, spectacles, hairpins, jewelry, body piercings).

    To be completed on day of investigation in the presence of a clinical staff member..

    Step 3

    I have read and understood the contents of this form and confirm that the above information is correct to the best of my knowledge. I have had the opportunity to ask questions regarding the information on this form and consent to the MRI and / or MEG procedure.








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