Medical Implants Information Sheet

The more information you are able to provide the easier it will be to research the implant and provide the most accurate answer as to whether the participant/staff member will be safe in a environment with an elevated magnetic field.

Participant’s medical information

Participant name: ____________________________________________________________________________ Maiden name: ____________________________________________________________________________ Date of birth: ____________________________________________________________________________

Contact information: ____________________________________________________________________________ ____________________________________________________________________________

Researcher name : ____________________________________________________________________________ Reseacher contact number : ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

  1. Type of surgery: ____________________________________________________________________________

  2. Type of implant: ____________________________________________________________________________

  3. Name of implant: ____________________________________________________________________________

    a. Model number: ____________________________________________________________________________

    b. Series number: ____________________________________________________________________________

    c. Manufacturer: ____________________________________________________________________________

    d. Year of surgery: ____________________________________________________________________________

  4. Hospital where surgery was done: ____________________________________________________________________________

  5. Medical record number: ____________________________________________________________________________

  6. RAMQ#: ____________________________________________________________________________

  7. Name of surgeon/doctor : ____________________________________________________________________________

All information above are included in the postoperative report / summary.

Does the participant have a card with contact information for this implant?