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E a history of a MRI contrast allergy? (If YES, pre-medication is required) Has the patient had surgery to the site to be examined? If YES, when, and what surgery? . Has the patient had previous MRI, CT, or X rays to the site to be examined? If so, what, where, and when: . I attest the above information is correct to the best of my knowledge. I have read and understand the entire contents of this form and I have had the opportunity to ask questions regarding the information on this form.

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