2008 Nine Road • Brady TX 76825-1150 • 325.597.
2901
MRI
PREGNANCY
CONSENT
FORM
INFORMED
CONSENT
TO
PROCEED
WITH
MRI
PROCEDURE
DURING
PREGNANCY
PATIENT
NAME:
_____________________________
DATE:
_________________
PLEASE
ANSWER
THE
FOLLOWING
QUESTIONS:
FEMALE
ONLY
1-‐4
1.
Are
you
pregnant
or
any
chance
you
may
be:
_______________
2.
Date
of
the
start
of
your
last
period:
________________
3.
Are
you
on
any
type
of
Birth
Control?
_______________
4.
Are
you
trying
to
get
pregnant?
Yes
/
No
This
consent
is
to
inform
you
the
Magnetic
Resonance
Imaging
(MRI)
procedure
you
are
having
today
is
at
a
possible
risk
to
your
unborn
child/fetus.
By
signing
this
you
are
consenting
to
understanding
all
of
the
information
below
and
have
asked
all
questions
needed
to
understanding
the
risks
associated
with
the
procedure.
To
date,
there
are
no
reports
of
injury
to
children
who
underwent
MR
imaging
before
birth.
While
the
number
of
patients
scanned
during
pregnancy
is
small,
with
limited
follow-‐up,
in
the
past
several
years,
numerous
pregnant
patients
have
undergone
MRI
with
no
ill
effects.
MR
imaging
of
pregnant
patients
is
carried
out
when
the
patient's
physician
has
decided
that
the
advantages
of
MRI
outweigh
the
potential
risks.
I,
_________________________________,
have
read
the
above
warning
and
understand
the
potential
harmful
effects
to
my
unborn
fetus.
I
consent
to
have
this
MRI
procedure
as
prescribed
by
my
physician.
I
acknowledge
that
I
have
been
given
ample
opportunity
to
ask
questions
and
that
all
questions
have
been
answered
to
my
satisfaction.
Furthermore,
I
fully
understand
that
I
may
refuse
to
have
this
MRI
procedure
conducted
on
me
without
any
obligation
to
Heart
of
Texas
Healthcare
System.
Also,
I
understand
that
I
may
stop
this
MRI
procedure
at
anytime
during
its
process.
Furthermore,
I
fully
agree
that
the
risks
described
herein
are
risks
that
I
am
willing
to
accept.
Also,
I
agree
that
I
will
hold
harmless
Heart
of
Texas
Healthcare
System,
owners,
and
employees
should
I,
or
my
fetus,
experience
any
negative
effects
from
this
MRI
procedure.
______________________________________
___________________
Signature
of
Person
giving
consent
Date
______________________________________
Printed
Name
of
Person
giving
consent
______________________________________
_______________________
Signature
of
Witness
to
Person
giving
consent
Relationship
______________________________________
___________________
Technologist
Date
