Please provide your contact information for us below:

1. First Name:
2. Age:
3. Gender:


4. Email:
5. Phone:


Because the study that you are volunteering to participate in involves receiving an MRI scan, there are a number of questions we must ask you to ensure your safety in the MR environment. The MRI scanner produces a constant strong magnetic field, which may cause any metal implants and/or clips within your body to shift position. The magnetic field may also cause any implanted medical devices to malfunction. Thus, if you have any implanted metal, clips or devices, it is hazardous to your health to participate in this study. Please answer the questions below as accurately as you can, so that we may decide whether it is safe for you to be a participant in this study.

Do you have any of the following:

Cardiac pacemaker or implantable cardioverter defibrillator (ICD)  Yes No
Aneurysm clip  Yes No
Pierced body parts that cannot be removed?  Yes No
Hearing aid or cochlear implant  Yes No
Permanent retainer or braces  Yes No
Dentures or partials  Yes No
History of bullets, shrapnel or BBs  Yes No
History of seizures  Yes No
Hairpiece, wig or hair extensions  Yes No
Tattoo or permanent makeup  Yes No
Stent or filter Yes No
Transdermal patch  Yes No
Are you claustrophobic?  Yes No
Have you ever had an injury to the eye involving a metallic object or fragment?  Yes No
Have you ever worked in a metal shop?  Yes No
Is there any possibility that you are pregnant?  Yes No
Are you currently taking any medications?  Yes No

If so, please list them here:


Have you had any previous surgeries?  Yes No

If so, please list them here: