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Location: Central London
Location: Central London
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Screening Form
First Name
*
Last Name
*
Email
*
Contact Number
*
Date of Birth
*
Address
*
GP Contact Details
*
Gender
*
Female
Male
Pregnancy
N/A
Yes
No
Technical Questions
Aneurysm clips or coils
Cardiac pacemaker or wires
Internal cardioverter defibrillator (ICD)
Carotid or cerebral stents
Deep brain stimulator
Metallic devices implanted in your head
Dental implants
Cochlear implant/ear implant
CSF (cerebrospinal fluid) shunt
Eye implants
Cardiac stents, filters, or metallic valves
Vagus nerve stimulator (VNS)
Blood vessel coil
Medication patch/nicotine patch
Wearable cardioverter defibrillator
Implanted insulin pump
Programmable shunt or valve
Hearing aid
Cervical fixation devices
Surgical clips, staples, or sutures
VeriChip microtransponder
Wearable monitor (e.g., heart monitor)
Bone growth stimulator
Wearable infusion pump
Radioactive seeds
Portable glucose monitor
Tracheostomy
Have ever had complication from an MRI?
No
Yes
Condition enquiring for.
*
How long have you been suffering from the condition?
*
Medications taken for your condition
Do you have epilepsy?
*
No
Yes
Have you experienced a seizure within the last 12 months?
*
No
Yes
Do you suffer from migraines?
*
No
Yes
Do you suffer from insomnia
*
No
Yes
Daily caffeine intake:
Recreational drugs?
Daily alcohol intake?
Are you currently on any other medication other than already stated?
Please note any other relevant information here:
When you prefer your treatment to start?
Asap
Next week
Next month
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