SUPPLEMENTAL MRI CONSENT
POTENTIAL INTRAOCULAR METAL FRAGMENTS
I have been told that because of my previous exposure to flying metal fragments there
may be undetectable metal in my eyes not seen on x-rays. Metal, which may be in my
eyes, could move in the magnetic field of the MRI scanner and possibly cause damaged
vision or blindness.
Alternative methods to evaluate my problem have been discussed with me.
I freely give my consent to undergo this exam knowing the increased risk.
SIGNATURE OF PATIENT DATE
SIGNATURE OF WITNESS