In accordance with ACR guidelines, all MR personnel working in the MR environment must complete this form to ensure their safety.

Personal items must be removed:

  • All metallic & magnetic objects
  • Wallets/ credit cards
  • Cellphones
  • Pagers
  • Keys
  • Safety Pins
  • Watches
  • Hair Elastics
  • Coins
  • Jewelry
  • Earrings/ Beads
  • Barrettes
  • Pocket Knife
  • Medals
  • Body Piercings

WARNING: Certain implants, devices, or objects may be hazardous to you in the MR environment or MR system room. Do not enter the MR environment or MR system room if you have any questions or concerns regarding and implant, device or object.

IMPORTANT INSTRUCTIONS

Remove all metallic objects before entering the MR environment or MR system room including hearing aids, beeper, cell phones, keys, eyeglasses, hair pins, barrettes, jewelry (including body piercing jewelry) watch, safety pins, paperclips, money clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knives, nail clippers, steel-toed boots/shoes and tools. Loose metallic objects are especially prohibited in the MR system room and MR environment.

Please consult the MRI Technologist or Radiologist if you have any questions or concerns BEFORE you enter the MR system room or MR environment.

Clear Signature
I attest that the information above is correct to the best of my knowledge. I have read and understood the entire contents of this form and have had the opportunity to ask questions regarding the information on this form. By completing and submitting this electronic form, I attest that this is accurate and I understand that I am required to notify Human Resources of any changes to this information.
ShieldsHealthLogo_WHITE with sports