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Vänligen ange uppgifterna nedan för att aktivera beställningen

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Rubrik *

Innehåll

Visuellt Text

Validera e-post

Validera e-post

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Har du eller har haft pacemaker (hjärtstimulator)? *

• Ja
• Nej

Har du opererats i huvudet, öron eller hjärtat? *

• Ja
• Nej

Har du eller har haft metallsplitter i ögonen eller annan kroppsdel? *

• Ja
• Nej

Har du eller har du haft några metallföremål i kroppen t.ex. ledprotes/stag/skruvar, shunt/pump, nervstimulator, hörselprotes (inopererad) etc? *

• Ja
• Nej

Har du svårt att vistas i ett trångt utrymme? *

• Ja
• Nej

För kvinnliga patienter, är du gravid? Ammar du? *

• Ja
• Nej

Längd (cm) *

Vikt (kg) *

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