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MRI Safety Questionnaire

Please complete the following questionare before your MRI

MRI Safety Questionnaire

MRI Safety Questionnaire

Patient Details

Booking Details

Do you have an MRI appointment booked with us?

Medical History

Have you had a previous MRI, or any related imaging related to this scan?
Do you suffer claustrophobia?
Have you ever had an eye injury caused by metal?
Have you had surgery or another procedure in the past 6 weeks?
Is there anything you would like the MRI staff to know to help make your scan more comfortable? (e.g., sensory or neurodivergent conditions, mobility needs etc)

Safety Information

Do you have or have you had.
A pacemaker, defibrillator, pacing wires or implanted cardiac device
An artificial heart valve
An electrical stimulator for nerves, brain or bone
An implanted or external infusion or drug pump
A shunt in your brain or spinal cord
Any coils, filters or stents
Any mechanically, electronically or magnetically activated implants
An aneurysm clip
Any eye or ear surgery
A gastric band
Any foreign pieces of metal objects, of any kind, in your body?
An Intra-Uterine Device (IUD)
Are you pregnant or do you suspect you may be pregnant
Are you currently breast feeding
If you have answered yes to one of the above questions, one of our MRI Modality Experts may contact you if we require further information.

Other Devices

Please indicate if you have.
Tattoos or permanent eyeliner
Any removable dental work, dentures or dental plates
Hearing aids
Any metal joints/pins, plates, rods, screws, nails or clips
Any medicated or metallic backed patches/dressings?
Any Continuous Glucose Monitor (CGM) or alternative monitoring device?

Contrast Dye

For some examinations, contrast dye may be used to improve the image of body organs and tissues.
Do you consent to contrast dye being used
Do you have renal (kidney) failure
If you have any allergies, please list them

Allergies

Next Appointment with your Doctor

Do you have an appointment with your doctor to discuss the results of this scan?

Release of Medical Information

Have you had any surgical procedure that involved the implantation of a device?

An implanted device may need to be researched to check its compatibility with our MRI systems. Please check this box to provide consent for Gibraltar Radiology to request the surgical notes from any relevant procedure to help ensure the safe undertaking of the MRI scan.

Upload Documents

To assist us with your appointment, please upload photos/scans of any relevant information such as your request form (if you have one) or implant card.

Have we already received a copy of your request form?
Do you have a copy of your request form?

Maximum file size: 5MB

Only .DOC, .DOCX, .PDF, .RTF, .ZIP, .RAR, .PNG and .JPG files (less than 5MB) accepted.
Do you have any other documents to send? ie. Implant card, previous report

Maximum file size: 5MB

Only .DOC, .DOCX, .PDF, .RTF, .ZIP, .RAR, .PNG and .JPG files (less than 5MB) accepted.

Pre Examination Information

It is likely you will be required to change into a gown prior to your examination (although some loose fitting sportswear may be acceptable). Your personal items will be stored securely. Before your scan you must remove all metal objects in your possession or on your body. This includes watches, mobile phones, credit cards, coins, keys, body piercings, earrings, hair clips, hearing aids, dentures, jewellery etc.

Disclaimer

I acknowledge to the best of my understanding that the above answers are true and correct and I consent to the MRI examination. Further, I acknowledge that Gibraltar Radiology has taken reasonable precautions and is not liable for any event that might result from incorrect answers on this form.
Disclaimer acknowledgement

Expert imaging. Clear answers. Compassionate care. Book your appointment today!

If you wish to make a booking or require urgent attention, please get in touch with our friendly team to make a booking.

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Please Note

We are NOT open to the public yet as our clinic is still under construction. Our official opening date is scheduled to be late February 2026.