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 Page 1 of 1