[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-307801-105":59,"doc-detail-307801-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","radiologie-important-questionnaire-for-mri","Radiologie - Important Questionnaire for MRI","","Radiologie Imagix Medical’s MRI request and patient questionnaire form collects referring dentist and report details, including preferred language (French/English), signature and licence information, and mandatory clinical and technical imaging data. It gathers patient identity, date of birth, phone and email, pregnancy status, and key contraindication screening for MRI such as pacemakers, metallic implants or clips, prostheses, body piercings/tattoos, recent surgery, claustrophobia, allergies, glaucoma, prior metallic eye injury, prior MRI history, and basic measurements like weight and height. It also includes locations for submitting the request by email to schedule an appointment.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/radiologie-important-questionnaire-for-mri/307801/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/radiologie-important-questionnaire-for-mri/307801.png","ImageObject",300,407,{"name":92,"@type":93},"River Wang","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",14,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What information is required from the referring dentist on the MRI report request form?","Question",{"text":113,"@type":114},"The form requires the referring dentist’s name/signature, licence number, date, and the report language preference (French or English).","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"Which MRI safety contraindications are screened in the questionnaire?",{"text":118,"@type":114},"It asks whether the patient has a cardiac pacemaker, metallic clips/implants or other prostheses, body piercings or tattoos, has had recent surgery within 12 weeks, is claustrophobic, is pregnant, has allergies or glaucoma, and whether there was prior eye injury with metallic material.",{"name":120,"@type":111,"acceptedAnswer":121},"How does the physician and patient submit the MRI request and schedule the appointment?",{"text":122,"@type":114},"The requesting party is instructed to complete the required section and send the request via email; the clinic will contact the patient to schedule the appointment.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},307801,1790072488,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":24},1099514067438,"https://ap-avatar.wpscdn.com/avatar/100002539ee87300030?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780474512215547542","TEL:  \n514 866-6622  \n1 866 916-6622  \nFAX:  \n514 738-1883  \nEMAIL:  \n[rx@imagixmedical.com](rx@imagixmedical.com)  \nRADIOLOGIE CHÂTEAUGUAY  \n230 Brisebois Blvd., Suite 201  \nChâteauguay (Quebec) J6K 0J6  \nRADIOLOGIE LAËNNEC  \n1100 Beaumont Ave.  \n(corner of Acadie) Suite 104  \nTown of Mount Royal (Quebec) H3P 3H5  \n233 Turgeon St., Suite 104  \nSainte-Thérèse (Quebec) J7E 3J8  \n\n| \u003Cbr>REFERRING DENTIST\u003Cbr>REFERRING DENTIST ADDRESS OR STAMP | REPORT\u003Cbr>q French q English |\n| --- | --- |\n| Referring dentist signature Licence \\# Date |  |\n\n\n| PATIENT |\n| --- |\n| Name:   Date of birth:   /   /  \u003Cbr>Tel:   Email:  \u003Cbr>qCNESST qSAAQ PREGNANT q YES q NO |\n\nMANDATORY CLINICAL INFORMATION  \nTECH.: DAP: NB IMAGES:  \nFORA CBCTORAN MRI, PLEASE COMPLETE THE SECTION BELOW AND SEND US YOUR REQUEST VIA EMAIL TORX@IMAGIXMEDICAL.COM.  \nWE WILL CONTACT YOU TO SCHEDULE AN APPOINTMENT.  \n\n| CONEBEAM CT |  |\n| --- | --- |\n| q Implant\u003Cbr>q Maxilla tooth \\#:  \u003Cbr>q Mandible tooth \\#:  \u003Cbr>q With radiological guide\u003Cbr>q With guide only (double scan)\u003Cbr>q Location of an impacted tooth and/or mandibular canal Tooth \\#:   | q Pathology / lesion search\u003Cbr>Region:  \u003Cbr>q Temporomandibular joints\u003Cbr>q 1 volume-closed mouth only\u003Cbr>q 2 volumes-mouth open and closed |\n| MRI | |\n| q Temporomandibular joints\u003Cbr>q Mouth open and closed\u003Cbr>qWith bite | q Panoramic view\u003Cbr>q Cephalometric view |\n\n09/2018 QA-PON-011 F11  \nMAGNETIC RESONANCE IMAGING (MRI)  \nIMPORTANT QUESTIONNAIRE TO BE COMPLETED BY THE PHYSICIAN AND THE PATIENT  \nLast name:   First name:   D.O. B.:   /   /    \nYES NO  \nThe patient has: q q  \nThe patient: q q  \na cardiac pacemaker  \ncerebral, neck or aorta metallic clip(s) . Specify:   metallic implant(s) or other devices. Specify:   prosthesis(-es): auditory, ocular, dental, capillary, joint or other. Specify:   rod(s), plate(s), nail(s), screw(s), as a result of a fracture or surgery. Specify:    \nbody piercing tatoo(s)  \nother(s) . Specify:    \nhas had surgery within the last 12 weeks is claustrophobic (if yes, plan medication)  \nis pregnant. Number of weeks:    \nhas allergies. Specify:    \nhas glaucoma.  \nhas had a prior eye injury involving a metallic foreign body. Specify:   has already had an MRI. Specify:    \nPatient’s weight:   Patient’s height:    \nI have completed the above questionnaire with my physician. I confirm that the information provided is accurate and I agree to undergo the magnetic resonance imaging examination.  \nDate:   Dentist’s signature:   Patient’s signature:    \nWHERE TO FIND US  \nMONTÉRÉGIE  \nRadiologie Châteauguay  \n230 Brisebois Blvd., Suite 201 Châteauguay QC J6K 0J6  \nMONTREAL  \nRadiologie Laënnec  \n1100 Beaumont Ave., Suite 104 Mont-Royal QC H3P 3H5  \nLAURENTIDES  \nRadiologie Sainte-Thérèse  \n233 Turgeon St., Suite 104 Sainte-Thérèse QC J7E 3J8  \n[Fax: 514 738-1883](Fax: 514 738-1883 | imagixmedical.com)[ |](Fax: 514 738-1883 | imagixmedical.com)[ imagixmedical.com](Fax: 514 738-1883 | imagixmedical.com)  \n09/2018 QA-PON-011 F11","cbCaiu1pGc3iZp27","https://ap.wps.com/l/cbCaiu1pGc3iZp27","pdf",343477,"English","# Mandatory Clinical Information\n## Patient Information and MRI Safety Questions\n## MRI/CT Imaging Options and Submission Instructions","[{\"question\":\"What information is required from the referring dentist on the MRI report request form?\",\"answer\":\"The form requires the referring dentist’s name/signature, licence number, date, and the report language preference (French or English).\"},{\"question\":\"Which MRI safety contraindications are screened in the questionnaire?\",\"answer\":\"It asks whether the patient has a cardiac pacemaker, metallic clips/implants or other prostheses, body piercings or tattoos, has had recent surgery within 12 weeks, is claustrophobic, is pregnant, has allergies or glaucoma, and whether there was prior eye injury with metallic material.\"},{\"question\":\"How does the physician and patient submit the MRI request and schedule the appointment?\",\"answer\":\"The requesting party is instructed to complete the required section and send the request via email; the clinic will contact the patient to schedule the appointment.\"}]","Radiologie - Important Questionnaire for MRI | PDF",1789855541]