"*" indicates required fields Patient Name*DOB* MM slash DD slash YYYY Date* MM slash DD slash YYYY Do you have any implants in your body? No Other Do you have any Heart monitors or sensors? Example: Pacemaker, Watchman Device, Loop recorder. No Other Do you have any Diabetic monitors or sensors? No Other Have you had brain surgery at any point in your life? No Other Have you ever had an eye injury involving metal? No Yes Have you had any surgeries or procedures within the last 6 weeks? Example of procedures: colonoscopy, endoscopy, etc.. No Other Have you had a tattoo within the last 2 weeks? No Yes Are you on any blood thinners? No Other Do you have kidney disease? No Yes Are you pregnant? No Yes
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