MRI Breast Bilateral IV Form

Are your implants saline or silicone? *

Do you have any implanted devices in your head or body (including sleep apnea device/stimulator)? *

Have you had any ear or eye surgeries? *

Do you wear a transdermal medication patch? *

Within the last 3 months have you ingested a pill camera or bowel capsule? *

Do you have any metallic objects lodged in your body such as bullets, BBs, or shrapnel? *

Do you use a continuous glucose monitor system such as Dexcom, Freestyle, or Libre? *

Have you had a Colonoscopy, Endoscopy, or Sigmoidoscopy in the last 3 months? *

Have you had any surgeries on the area being scanned? *

Do you have a pessary ring (for bladder support)? *