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) YesNo
Aneurysm clip YesNo
Pierced body parts that cannot be removed? YesNo
Hearing aid or cochlear implant YesNo
Permanent retainer or braces YesNo
Dentures or partials YesNo
History of bullets, shrapnel or BBs YesNo
History of seizures YesNo
Hairpiece, wig or hair extensions YesNo
Tattoo or permanent makeup YesNo
Stent or filterYesNo
Transdermal patch YesNo
Are you claustrophobic? YesNo
Have you ever had an injury to the eye involving a metallic object or fragment? YesNo
Have you ever worked in a metal shop? YesNo
Is there any possibility that you are pregnant? YesNo
Are you currently taking any medications? YesNo

If so, please list them here:


Have you had any previous surgeries? YesNo

If so, please list them here: