INFORMED CONSENT FOR MRI DURING PREGNANCY
Your physician, Dr.______________, feels that it is necessary that you have a Magnetic
Resonance Imaging (MRI) procedure to evaluate your disease prior to treatment. This
exam combines radio frequency waves and a magnetic field. This scanning procedure is
approved for general use in adults and children but has not, to date, been approved by the
FDA for use during pregnancy. Your signature at the bottom of this consent form
indicates that you have been told this fact and the benefits and risks of the procedure have
been explained to your satisfaction. You further release this facility, Shawnee Open
MRI, the MRI staff and physicians from any liability should there be any subsequent
problems with your pregnancy or your unborn child.
The technologist will answer any questions that you may have regarding this test.
There are no known adverse effects from MRI to a pregnant woman and/or the fetus.
I UNDERSTAND WHAT IS INVOLVED IN THIS TEST AND AGREE TO TAKE
PART IN THE PROCEDURE. I UNDERSTAND THE REASONS FOR THIS
PROCEDURE. I UNDERSTAND THAT THERE ARE NO KNOWN ADVERSE
EFFECTS TO ME OR MY UNBORN CHILD.
Patient Signature:__________________________________Date:___________________
Referring Physician:_______________________________________________________