Canopy Imaging - MRI Safety Checklist

First name

Last name

NHI number (if you know it)

Date of Birth

Male

Female

Phone number (9am-5pm)

Mobile number

Email

Address

City / Region

Post code

Please provide an emergency contact and their contact details (mobile phone number preferred).

Referring Specialist

GP

GP Practice name

Would you also like a copy of the report to be sent to your GP?

Yes

No

Do you have any COVID related symptoms?

Yes

No

Is the cost of your MRI covered by ACC?

Yes

No

ACC number (if you know it)

Do you have medical insurance?

Yes

No

Please confirm if you are paying for this service privately?

Yes

No

MRI examinations use a very strong magnetic field

The following questions are designed for your safety, and to produce the best quality images possible.

Height (if you're not sure, please enter approximate)

Weight (if you're not sure please enter approximate)

Is there any chance you could be pregnant?

Yes

No

Do you have or have you EVER had a cardiac pacemaker or an ICD (Implanted Cardioverter Defibrillator)?

Yes

No

Have you EVER had an eye injury involving a metallic fragment?

Yes

No

Have you EVER had heart surgery?

Yes

No

Date of surgery, make and model of implant, name of hospital where surgery was conducted:

Have you EVER had eye, inner ear, head or brain surgery?

Yes

No

Date of surgery, make and model of implant, where on the body the surgery occurred, name of hospital where surgery was conducted:

Have you EVER had surgery to your arteries or veins that involved a stent / graft or any type of implant being inserted?

Yes

No

Do you have ANY metallic, electronic or mechanical implants or devices, or had an injury to your body involving metal? i.e. cochlear implant, drug infusion device, diabetic glucose monitor, shrapnel/bullets.

Yes

No

Have you had ANY pervious surgery/operations?

Yes

No

Do you wear any medication skin patches?

Yes

No

Do you suffer from Claustrophobia? (eg are uncomfortable in small spaces, like lifts?)

Yes

No

Have you had any endoscopic procedures within the last 6 week? (including colonoscopy/gastroscopy)

Yes

No

If yes, please provide date/hospital/any clips used?

Do you need assistance with mobility? (walking or lying down)

Yes

No

Have you had any previous imaging of this area before?

Yes

No

Do you have a history of Kidney disease?

Yes

No

Have you had a previous reaction to Gadolinium (MRI Contrast)?

Yes

No

Do you have difficult vein access?

Yes

No

Do you have any allergies?

Yes

No

Do you have any bleeding conditions?

Yes

No

Are you taking any blood thinning medication? (eg aspirin, warfarin clopidogrel or pradaxa)

Yes

No

Are you wearing any hard to remove jewellery, magnetic cosmetics, fiber hair products, piercings or electronic devices? If yes, please remove prior to your appointment. (no need to cut off wedding rings)

Yes

No

Child Supervision Policy

Because we care about your safety and the safety of your children we have very strict guidelines about supervising children. If a child under the age of 12 years is coming with you to your appointment, a person over the age of 14 must also attend and be able to supervise them.

Tattoos

Please note that we do not recommend getting a tattoo 48 hours prior to your appointment as the procedure can cause damage to the tattoo.

Please advise the date of your follow up appointment with your specialist, if you have one.

Referral Form

Please upload the referral form that your medical professional gave you as this is required before we can proceed further. If your medical professional forwarded your referral form directly to us, please confirm by ticking the box.

Yes

File upload

If you have any questions or concerns please feel free to contact us. We are here to help.

Canopy Imaging
Whangarei 09 430 3045
Auckland 09 487 2555
Rotorua 07 349 5780
Hawkes Bay 06 873 1166