CT Safety Questionnaire

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01/22/2025
Name*
MM slash DD slash YYYY
Safety Question ( for women only): Any chance you are pregnant?
Do you have a history of cancer?

Instruction for the Patient, Parent or Guardian:

We will provide a locker or changing room so all items you remove may be stored and locked safely during your scan. You may bring the key in the scan room with you.
1. Remove any jewelry, body piercings, or hair accessories in the area of the examination.
2. Remove dentures, partial dental plates, retainers (for brain, head or neck examinations).
3. Remove hearing aids and eye glasses (for brain, head, neck examinations).
4. Lock your clothes and valuables in the locker or room provided and remove the key.