MRI INFORMED CONSENT
FOR PREGNANT PATIENTS
PLACE LABEL HERE
PATIENT NAME: _________________________________________ DATE: _________________________
TIME: _________________________
The diagnosis or clinical history requiring this procedure is: _________________________________________
________________________________________________________________________________________
BENEFITS OF MRI:
MRI is a powerful imaging device that does not use radiation. It has the potential to provide information
that may change your diagnosis, care, and/or therapy of you and your fetus.
POTENTIAL RISKS:
The Food and Drug Administration (FDA) cautions that the full effects of MRI during pregnancy have
not yet been determined. Presently there are no known ill effects associated with MRI. MR
imaging may be used in pregnant women if other non-ionizing forms of diagnostic imaging are
inadequate or if the examination provides important information that would otherwise require exposure
to ionizing radiation. You may consult with your physician if you have any questions about the effects
of the MRI and the fetus.
ALTERNATIVES:
There are other procedures such as Nuclear Medicine Scan, Ultrasound, CT Scan, Arteriograms and
surgical procedures, which may yield diagnostic information pertaining to your condition. However,
these procedures may not provide the same depth of information or may have more associated risk.
I have read the above statements and had the opportunity to ask questions regarding the information
on this form and regarding the MR procedure that I am about to undergo.
____________________
______________
__________________________________________________
Date
Time
Person Giving Consent
Witnessed by:
at the direction of
Signature of Person Obtaining Consent
Name of Responsible Physician
Relationship to Patient if not the patient:
Patient unable to sign because:
Patient / Person giving consent refused procedure:
*1-19713*
FORM 1-19713
REV. 10/2010
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