MRI Requestor Registration

MRI requestor application

APPLICANTS

Please provide all of the details required in the form below. Once completed, a copy will be emailed to your Clinical Supervisor for approval.

Note: this form is for MRI requestor registrations only. for all other registrations please select the New Registration form from the menu above.

First name:

Please complete

Last name:

Please complete

Email Address:

Please complete with a valid Email Address.

Job Role

Please complete

Date MRI Training Completed:

Please complete

Professional registration No:

Please complete

Clinical supervisor - Name:

Please complete

Clinical supervisor - Role:

Please complete

Clinical supervisor - Email:

Please complete with a valid NHS Email Address

Are you a FULLY INDEPENDENT PRACTITIONER?

I diagnose and treat patients in clinical practice, but a consultant is ultimately responsible for my patients.

Please confirm

OR

I work as a fully independent practitioner with my own patient list and take complete responsibility for my own patients without consultant oversight.

Please confirm

New MRI application

Please confirm

3 year renewal

Please confirm

By submitting this you are confirming that:

I have read and understand CG24
I have read and understand The Proxy Consent Form
I have read and understand Referring for MRI Leaflet
I have read and understand The Foreign bodies and Implants form
I have read and understand The MRI Pregnancy Information leaflet
I have watched The MRI Safety Training Video

Within the training I have covered

Knowledge of safety aspects of referring patients for MRI scans
Knowledge of contraindications to Gadolinium and Gadolinium containing contrast agents
As part of this extended scope my role is to -

Verify that the patient is aware of the reason for the MRI requested
Explain the risks and benefits of MRI
Explain the alternatives to MRI including risks and benefits
Answer patient's questions/concerns
Verify the patient understood the information given and verbally consented to have MRI
Identify sources of information patient may wish to access

Contraindications to MRI

Cardiac Pacemakers
Cochlear or other ear implant
Implanted neuro-stimulator
Intracranial vessel clip(s)
Programmable hydrocephalus shunt
Cardiac stent (check type - not all are excluded)
Small metal fragments in eyes (arranges orbital x-ray if any doubt)
Shrapnel injury (eg, bomb blast or gunshot)
1st trimester pregnancy
Severe renal impairment (GFR < 30 ml/min/1.73m2)

I understand that this competency lasts for 3 years and after this time I must refresh myself on the above materials, and make a refresher application.