Can this consent be e-signed?

Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met.

What authentication is sufficient?

Reasonable authentication depends on risk and facility policy; email link or SMS code is common. Use stronger methods (KBA, multi-factor) for high-risk situations or institutional requirements.

How are minors handled?

Minors generally require guardian consent unless state law permits minor consent for specific services; document authority and attach supporting legal documentation when a representative signs.

Can a patient revoke consent?

Yes. A patient may withdraw consent prior to the procedure; document revocation, reason, and subsequent provider actions in the medical record.

How long must signed consents be kept?

Retain consents per HIPAA and state rules; HIPAA requires six years (45 CFR §164.530(j)), and many facilities retain records longer for risk management.

Is notarization required?

Not typically for routine medical consent. Notarization or witness requirements are uncommon for MRI consents but check state or institutional policies if specialized formalities are needed.

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Informed Consent for Non-Contrast MRI

Informed Consent for Non-Contrast MRI

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

Informed Consent and MRI Patient Forms

Informed Consent for Non-Contrast Magnetic Resonance Imaging (MRI)

Patient’s Name Date of Birth

What Is MRI?

Magnetic resonance imaging (MRI) uses a very strong magnet and radio waves to produce images of the body, allowing the doctor to visualize bones, tendons, ligaments, and soft tissues. When appropriate, we inject a special contrast called gadolinium to add valuable information to your examination.

Why Is an MRI Examination Beneficial?

Depending upon the specific type of MRI procedure performed, the doctor will be able to visualize the inside of your ligaments and tendons, revealing partial as well as large muscle tears, sprains, and strains. MRI shows us the inner portions of bone and can reveal tumors or bone bruises, as well as cartilage tears. MRI can also reveal improper blood flow, aneurysms, strokes, tumors, and certain other disorders of the brain. Spinal cord abnormalities and other sources of back pain can also be seen.

How Do I Prepare for an MRI Examination?

In most instances no special preparation is necessary. There are no food or drink restrictions unless your doctor orders certain rare examinations of your abdomen, and you should continue to take any medications prescribed by your doctor unless otherwise directed. You won’t be allowed to wear street clothes or anything metallic, like jewelry, during the examination. The MRI scanner will make a loud “knocking” noise, so hearing protection such as earplugs or headphones will be supplied to you by the center. Examination times commonly range from 20 to 60 minutes and it is important to lie still during the entire examination because movement degrades the quality of the images.

What Are the Risks?

For most people, MRI is one of the safest medical imaging examinations because it involves no harmful radiation. MRI is not painful and there are no known harmful effects to the body. Patients who may be pregnant should always advise their physician and the technologist before the appointment so they can exercise additional caution. Patients with claustrophobia often find MRI examinations unpleasant because of the confining feeling of the equipment.

The MRI scanner produces a very powerful magnetic field that will attract certain metallic objects that contain even small amounts of iron. Some patients cannot safely undergo MRI examination because of metal in their bodies. Examples include pacemaker, implantable cardioverter defibrillator (ICD), neurostimulator, aneurysm clip, metal implant, implanted drug infusion device, or other implants that utilize magnets.

What Are the Alternatives?

In most instances MRI provides a more detailed image of the body than other types of scans. In some cases, depending on individual factors, there may be alternatives to having an MRI scan.

• X-ray

• Computed Tomography (CT) Scan

• Ultrasound

• Nuclear Medicine Scan

By signing this you agree that you have read this form and/or received oral communications of all the information provided in this form. You understand the information and have had any questions answered regarding this procedure and who will read the exam.

Patient’s and/or Appropriate Agent’s Signature

Date

HIPAA Acknowledgment & Office Policies

BY SIGNING BELOW, I HEREBY ACKNOWLEDGE AND AGREE TO THE FOLLOWING POLICIES:

Responsibility for Valuables

ProScan does not assume responsibility for securing any valuables or personal items belonging to patients or visitors.

I have read and understand the above statements.

Children in the Waiting Room

ProScan is not responsible for providing supervision of any child during your imaging exam.

I have read and understand the above statements.

Cancellation Policy

If you miss or cancel your appointment without giving the appropriate 24-hour notice, ProScan may charge a $50.00 cancellation fee.

Notice of Privacy Practices

I hereby give my consent for ProScan Imaging and Affiliated Entities to release my protected health information to the following individual(s):

For ProScan Imaging Use Only – Receipt of Notice of Privacy Practices Only

Date Acknowledgment Received

Initials

Reason Acknowledgment was not obtained

Patient or Legal Representative Signature

Date

Print Name

Relationship/Authority if Legal Representative

Pediatric Radiology Health History Form

Patient Name

Date of Service

Nick Name

DOB

Age

Sex

Height

Weight

What is the number one symptom your child is experiencing?

Where is the problem or where does it hurt?

How long has the problem been going on?

What do you think is causing the problem?

Is your visit due to an accident or trauma?

Yes No

If yes, was it a car accident?

Yes No

Is your child currently experiencing any pain?

Yes No

Please list all major medical history, including all surgeries and drug allergies.

Please list any other MRIs, X-rays, CT scans or Ultrasounds your child has had of the area we are imaging today and the date.

Contrast Injected?

Yes No

Time

AM/PM

Contrast Brand Name

Dosage

Route Administered

Administration site

Lot

Expiration Date

Reaction?

Signature of technologist

Signature of Physician Supervising Contrast

Patient Safety Screening for MRI

WARNING! IF YOU HAVE A PACEMAKER, DEFIBRILLATOR OR ANEURYSM CLIP, DO NOT PROCEED WITH YOUR SCAN.

Patient Name

DOB

Appt. Date

Please indicate if you have any of the following implants or metal inside your body:

Yes No Cardiac Pacemaker Yes No Cardiac Defibrillator (ICD) Yes No Heart Valve prosthesis Yes No Aneurysm Clip Yes No Metallic stent, filter or coil Yes No metallic foreign body in eye

IMPORTANT INSTRUCTIONS!

Before entering the MRI environment or MRI system room, you must remove ALL metallic objects, including hearing aids, dentures, partial plates, keys, pagers, cell phones, eyeglasses, jewelry, and other metal objects.

Signature of Person Completing Form

Form Completed by

Patient Other

Relationship to patient

Form Reviewed by

Reviewer Type

MRI Tech. Rad. Tech. Assist. Coordinator

I have reviewed this form. All positive responses have been discussed, investigated and cleared.

Signature of Technologist

Date

What the Informed Consent for Non-Contrast MRI Is

The Informed Consent for Non-Contrast MRI is a written record that documents a patient's voluntary agreement to undergo an MRI scan without intravenous contrast. It explains the procedure, expected benefits, common and uncommon risks, alternatives (including declining the exam), and the patient's right to ask questions. The form records identity, signatures, dates, and any specific instructions or restrictions from the ordering clinician, creating a medical-legal record of communicated information and consent.

Why a Clear Consent Form Matters

A clear informed consent protects patient autonomy and supports clinical documentation. Properly completed consents reduce legal risk, support billing and clinical decisions, and serve as evidence of communication in case of questions or complaint.

Who Completes and Signs This Consent

Typical participants include the patient, the ordering clinician, and the radiology team who confirms understanding and captures signatures.

Patients or legally authorized representatives: confirm identity, ask questions, and sign to document voluntary agreement.
Ordering clinicians: explain indications, answer questions about alternatives, and document clinical necessity and any restrictions.
Radiology staff or technologists: review the form, verify safety screening (implants, devices), and capture witness or electronic signature.

The consent process may also involve a legally authorized representative when a patient lacks capacity or is a minor.

Common Signer Roles

Radiology Nurse

A radiology nurse typically reviews the consent with the patient, documents the safety screen, instructs on exam preparation, records the patient signature, and notes any questions or refusals in the medical record.

Ordering Physician

The ordering physician explains the medical rationale and alternatives, documents informed discussion in the chart, and may sign to confirm that the patient received appropriate counseling before the exam proceeds.

Essential Elements of a Professional Consent Form

A complete consent form for a non-contrast MRI combines procedure details, risk disclosure, alternatives, screening, and signature blocks so the record is clinically useful and legally defensible.

Procedure Description

Concise explanation of MRI purpose and what the patient will experience, including positioning and expected duration, to set realistic expectations and document disclosure.

Risks and Discomforts

Plain-language list of common and rare risks (claustrophobia, noise, thermal effects), and specific device interactions, so patients can weigh benefits and risks.

Alternatives

Non-imaging alternatives or alternative imaging modalities should be listed where relevant, enabling informed choice and documenting the clinical discussion.

Safety Screening

Targeted questions about implants, pacemakers, bullets, or ferromagnetic material that could contraindicate MRI or require modification of protocol.

Signature Block

Fields for patient name, date of birth, signature, date, and space for witness or representative signature if required by facility policy or state law.

Special Notices

Disclosure for pregnancy status, sedation plans, or referral to contrast in future exams, plus instructions for revocation and additional questions.

Step-by-Step: Completing the Consent Before the MRI

Follow these sequential steps to obtain valid informed consent and prepare the patient for a non-contrast MRI.

01

Verify Identity: Confirm name and DOB against the medical record.
02

Explain Procedure: Describe purpose, duration, and what to expect.
03

Review Risks: Discuss common and rare risks, and alternatives.
04

Capture Signature: Obtain patient or representative signature and date.

Configuring Online Consent Workflows

Standard workflow settings ensure consistent collection, verification, and storage of consent records.

Field	Configuration
Authentication Method	Email link or SMS code for signer verification.
Conditional Questions	Show pregnancy or implant screens when relevant.
Audit Trail Settings	Record IP, timestamp, and signer actions.
Storage Location	Save signed PDFs to EHR or secure cloud.

Technical Requirements for eConsent Systems

Ensure the platform supports secure file types, signer authentication, and integration with your health record system.

File Formats: PDF and DOCX supported
Integrations: Connects to EHRs and cloud storage
Authentication: Email, SMS, or SSO options

Typical eConsent Flow From Request to Record

This sequence outlines a standard digital consent lifecycle and the core checkpoints to validate consent.

Upload Form: Load template into eSignature system.
Place Fields: Add signature, initials, and date fields.
Send to Signer: Deliver via email or secure link.
Store Record: Save signed PDF and audit trail.

Security and Compliance Essentials

Encryption in Transit: TLS 1.2 / TLS 1.3

Encryption at Rest: AES-256 encryption

HIPAA: BAA required for PHI

Audit and Controls: SOC 2 Type II available

International Standard: ISO 27001 certified

FDA Records: 21 CFR Part 11 supported

Common Preparation and Completion Errors

Incomplete patient identifiers or mismatched names lead to record linkage failures and potential billing denials if not corrected before imaging.
Failing to document capacity or legal authority when a representative signs can expose providers to consent disputes and administrative reviews.
Skipping the safety screening for implants or devices increases clinical risk and can result in cancelled scans or patient harm.
Using ambiguous language about risks or alternatives undermines informed decision-making and weakens the medical-legal defense of the consent.

Legal and Clinical Risks of Improper Consent

Civil Liability: Malpractice claim exposure

Regulatory Action: State medical board discipline

Record Rejection: Billing or audit denial

HIPAA Breach: Potential regulatory fines

Patient Harm: Clinical adverse events

Evidentiary Weakness: Insufficient documentation

Timing Considerations and When to Obtain Consent

Timing follows clinical urgency, state law, and facility policy: document consent before the exam when feasible and note exceptions for emergencies.

Standard Timing:

Obtain prior to the scheduled MRI

Emergency Exception:

Document verbal consent and reason

Sedation or Anesthesia:

Consent required before sedation administration

Minors:

Obtain guardian consent unless law provides otherwise

Revocation:

Patient may withdraw consent any time prior

Key Process Milestones for Consent Collection

Use these sequential milestones to ensure the consent is complete, reviewed, and stored as part of the imaging workflow.

01

Pre-Visit Screening

Safety questionnaire and scheduling confirmation

02

In-Person Review

Clinician or nurse discusses the procedure

03

Signature Capture

Patient or representative signs consent

04

Record Filing

Signed form stored in EHR and audit log

Real-World Use Examples

These anonymized examples show how facilities handle non-contrast MRI consents in different operational contexts.

Community Hospital

A nurse-led consent workflow reduced pre-scan delays by clarifying screening steps

staff training improved consistency
the hospital documented higher on-time start rates and fewer scan cancellations by tracking incomplete consents and corrective actions.

Outpatient Imaging Center

An outpatient center implemented electronic consent links sent before appointments

patients completed forms at home
the center reduced front-desk time and ensured signed PDFs were available to technologists at check-in.

eSignature Vendor Comparison for Consent Workflows

Compare core pricing and feature availability across common eSignature vendors; signNow appears first in the table per supplier ordering guidelines.

	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, no credit card	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

FAQs: Common Questions About Non-Contrast MRI Consent

Answers to frequent questions about validity, electronic signatures, minors, and recordkeeping for non-contrast MRI consents.

Need help? Contact support

Can this consent be e-signed?
Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met.
What authentication is sufficient?
Reasonable authentication depends on risk and facility policy; email link or SMS code is common. Use stronger methods (KBA, multi-factor) for high-risk situations or institutional requirements.
How are minors handled?
Minors generally require guardian consent unless state law permits minor consent for specific services; document authority and attach supporting legal documentation when a representative signs.
Can a patient revoke consent?
Yes. A patient may withdraw consent prior to the procedure; document revocation, reason, and subsequent provider actions in the medical record.
How long must signed consents be kept?
Retain consents per HIPAA and state rules; HIPAA requires six years (45 CFR §164.530(j)), and many facilities retain records longer for risk management.
Is notarization required?
Not typically for routine medical consent. Notarization or witness requirements are uncommon for MRI consents but check state or institutional policies if specialized formalities are needed.

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