Robin Anderson

 
 RE2116527 
 MRI Patient History and Questionnaire 
 Patient Name JUSTIN GARIBALDI 
 CIS163316 
 birthdate 1992-14-02 
 Patient 256 
 The following list consists of items that can interfere with MR Imaging, or if present, can be hazardous to 
 your safety.
 Pacemaker/ Defibrillator 
 Yes 
 No 
 Cardiac Stent 
 Yes 
 No 
 Brand and ID# 
 List ALL Surgeries 
 0 
 Please remove all jewelry and hairpins prior to going into MRI suite for exam 
 I have completed this questionnaire and answered all questions to the best of my knowledge. 
 2020-01-02 
 Patient Signature 
 Date 
 Patient% Representative 
 Date 
 Kelly 
 Signature Babing 
 2020-01-02 
 Technologist's 
 Date