Establishing secure connection…Loading editor…Preparing document…

Healthcare Open MRI Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare Open MRI Form

PATIENT INFORMATION

Patient Name:

Date of Birth:    Gender:

EMERGENCY CONTACT

INSURANCE INFORMATION

MEDICAL HISTORY

Pregnant or possibly pregnant? Check if yes:   If yes, date of last menstrual period:

IMPLANTS, METAL AND DEVICE SCREENING

For each item below, check the box if it applies to you. If none apply, leave blank.

MRI SAFETY AND EXPOSURE HISTORY

Please check any of the following that apply to you:

CONTRAST AGENT (IF ORDERED)

The ordering provider may request the use of a gadolinium-based contrast agent to improve diagnostic accuracy. Check to consent to contrast if ordered:

PATIENT RIGHTS, RISKS, AND CONSENT

I understand that an Open MRI is a diagnostic imaging procedure that uses a strong magnetic field and radiofrequency energy to produce images of internal structures. The procedure is noninvasive. Risks include, but are not limited to: unforeseen reaction to contrast agents (if used), movement artifact reducing image quality, and the potential for heating or displacement of metallic implants or fragments. There is a small risk of worsening of symptoms in patients with certain implanted devices.

I have informed the technologist and physician of all implants, devices, allergies, recent surgeries, and pregnancy status to the best of my knowledge. I understand that providing incomplete or inaccurate information may increase the risk of harm. I may withdraw my consent at any time prior to the scan without affecting my right to future care.

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize release of my MRI images and report to the referring provider and other treating healthcare professionals for purposes of diagnosis and treatment. I acknowledge that the facility may use or disclose protected health information for treatment, payment, and health care operations as set forth in the facility's privacy practices.

Authorization expires on:

By signing below I certify that I have read and understand the information above, that the information I have provided is accurate to the best of my knowledge, and that I consent to undergo the Open MRI examination as ordered by my physician. I have had the opportunity to ask questions which were answered to my satisfaction.

AUTHORIZED RELEASE (OPTIONAL)

I authorize release of exam results to the following person(s): Name:

Relationship:    Phone:

Patient Printed Name:

Signature:

Date:

If signed by guardian, print name and relationship:

Guardian/Representative Phone:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Healthcare Open MRI Form Is and When It’s Used

The Healthcare Open MRI Form is a patient intake and safety screening document used before an open magnetic resonance imaging (MRI) procedure. It collects medical history, implanted device information, allergy status, pregnancy likelihood, and consent to proceed with imaging while documenting patient understanding of MRI risks and instructions. Facilities use it to confirm eligibility for an open MRI, to capture informed consent, and to create a permanent clinical record tied to the imaging encounter for scheduling, billing, and compliance purposes.

Why a Clear, Complete MRI Screening Form Matters

A properly completed Healthcare Open MRI Form reduces safety incidents, prevents wasted scanner time, and documents informed consent for legal and clinical continuity purposes. Accurate screening ensures contraindications are identified and mitigations are documented.

Why a Clear, Complete MRI Screening Form Matters

Who Typically Completes and Reviews This Form

Proper role separation ensures the patient provides consent, a clinical reviewer confirms safety, and the record is retained in the health record for compliance.

  • Patient or authorized representative completes the form at intake using clinic-provided paper or an online portal.
  • MRI technologist verifies answers, confirms ID, and documents any safety measures required for imaging.
  • Ordering clinician or radiologist reviews critical items (implants, pacemakers, contrast allergies) before final approval.

Core Sections to Include in a Professional MRI Screening Form

A complete Healthcare Open MRI Form groups patient identifiers, safety screening questions, device/implant details, contrast and allergy history, informed consent text, and signature blocks for patient and staff.

Patient ID

Full legal name, date of birth, medical record number, and contact details to match the imaging order and prevent wrong-patient procedures.

Safety Questions

A structured checklist about metal in the body, implants, prior surgeries, and occupational exposures that could contraindicate MRI or require modifications.

Implant Details

Fields for implant type, model, date implanted, and MR-conditional status so technologists can evaluate scanner compatibility.

Contrast & Allergies

Allergy history, prior contrast reactions, renal function flagging (if relevant), and clinician instructions for contrast administration.

Informed Consent

Plain-language consent statement describing risks, benefits, alternatives, and space for patient questions and verbal confirmations.

Signatures

Designated signature fields for the patient (or representative) and verifying technologist with dates and printed names for the medical record.

Required Information Elements to Capture

Legal Name: Patient full name
DOB: MM/DD/YYYY
MRN: Medical record number
Implant Status: Yes / No / Unknown
Allergy History: List or None
Signature: Patient or rep signature

Step-by-Step: Completing the Healthcare Open MRI Form

Follow these steps in sequence to complete screening, confirm eligibility, and record consent before the MRI exam.

  • 01
    1. Verify ID: Confirm patient identity and match to order.
  • 02
    2. Complete Screening: Answer safety checklist items fully and honestly.
  • 03
    3. Review Implants: Confirm MR-conditional status or escalate to radiology.
  • 04
    4. Sign and File: Patient and technologist sign; upload to the EHR.

Configuring an Online Workflow for the MRI Form

Basic configuration steps for digitizing the Healthcare Open MRI Form in an e-signature platform or patient portal.

Field Configuration
Patient ID Field Pre-fill from scheduling system to reduce errors
Conditional Questions Show implant detail fields only when 'Yes' selected
Authentication Require email or SMS code to attribute signers
Audit Trail Capture IP, timestamp, and completion certificate

Where the Completed Form Goes and Who Sees It

After completion, the form should be routed to clinical staff and stored in the electronic health record according to facility policy.

  • Technologist Review: Technologist receives and verifies form before scan
  • Radiologist Notification: Critical flags sent to radiology for approval
  • EHR Upload: Signed form archived in the patient's chart
  • Billing Attachment: Form attached to imaging encounter for claims

Technical Considerations for Electronic Forms and Signatures

Platforms that support integrations with EHRs, SSO, and secure storage can streamline workflow while maintaining HIPAA-compliant records and access controls.

  • Format Support: PDF, DOCX, and image files
  • Authentication: Email or SMS code
  • Audit Trail: IP and timestamp logging

Timelines and Typical Processing Expectations

Timing expectations help avoid last-minute cancellations and ensure safety checks are completed before patient arrival.

Pre-Appointment Completion:

Ideally 24–72 hours before exam for clinician review

Same-Day Review:

Technologist rechecks answers at arrival

Urgent Escalation:

Immediate radiology review for MR-unsafe flags

EHR Archival:

Store immediately after signatures

Retention Trigger:

Retention schedule begins at creation date

Common Errors That Delay MRI Appointments

  • Incomplete implant details requiring phone follow-up and potential appointment rescheduling.
  • Mismatched patient identifiers between the form and imaging order causing hold-ups at check-in.
  • Failure to disclose recent surgeries or implants that change MR-conditional status.
  • Using initials instead of full signatures or missing dates that make the consent invalid.

Risks and Compliance Consequences of Poor Documentation

Patient Safety: Risk of harm or adverse event
Clinical Delays: Scan cancellation or rescheduling
Regulatory Exposure: HIPAA breaches or audit issues
Billing Denials: Claims may be questioned
Legal Liability: Informed-consent disputes
Record Integrity: Incomplete medical record

Representative eSignature Vendor Comparison for Healthcare Forms

A concise comparison of common eSignature vendors and key attributes relevant to handling Healthcare Open MRI Forms and patient consents.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

FAQs: Electronic Signing and Common Questions for MRI Forms

Answers to frequently asked questions about consent validity, HIPAA concerns, witness requirements, and correcting completed MRI forms.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.