Prostate MRI Health
Prostate MRI Health Prostate MRI Health Prostate MRI Health Prostate MRI Health
 

Prostate MRI Health

Request Form MP MRI Prostate

PLEASE NOTE: Required fields marked *

 

Date of birth*

 
 

Examination request

Is the patient Diabetic?

Does patient suffer from Nocturia?

Detection

YES

YES

Watchful Waiting

NO

NO

 
 
 
 
 
 

Hormone treatment

Allergic reaction to Gadolinium

Current hormone treatment

YES

YES

YES

NO

NO

NO

 
Poor Kidney Function

YES

NO

 

Contraindications*

Metal splinters in body/eyes

Implanted jaw magnets

Hearing Prosthesis / Cochlear Implant

Claustrofobic: Warn Patient

No Contraindications

 
 
 
 
 
 
 
* Required fields