ROYAL NATIONAL ORTHOPAEDIC NHS TRUST

PATIENTS FOR MRI WHO ARE PREGNANT

Must be completed in all cases and scanned onto RIS. Please remember to keep all scanning to a minimum and only scan in low SAR.

Patient Name:…………………………………. …...Hosp.No………………………

LMP:……………………………………………

I understand that if I have an MRI scan whilst pregnant that there may be risks to the baby.

The radiographer has explained the risks and I am happy to proceed.

Signed…………………………………………… Date……………………….

Radiographer signature…………………………………………………………..

Body Part…………………………………………….

Sequences required:

SEQUENCES(Radiologist to complete)

SAR(Radiographer to do)

SCAN TIME(Radiographer to do)

Radiologist’s Signature………………………………………………………………..