QUALIFYING FOR TULSA

*PLEASE NOTE* If you do not qualify for TULSA-PRO, you may be eligible for HIFU treatment.

Do you have any of the following:

• Cardiac pacemaker/pacemaker lines
• Automatic Internal Cardiac Defibrillator
• Brain Aneurysm clips
• Cochlear implant (ear surgery)
• Cardiac Surgery in last 6 weeks
• Tissue expander prior to breast implant

***If the patient answered yes to ANY of the above, the patient is ineligible for an MRI procedure at Choice Diagnostic Imaging and the TULSA procedure. ***

IF YOU ANSWERED NO TO THE ABOVE AND HAVE ALREADY HAD A 3T MRI, THEN YOU WILL QUALIFY. YOU WILL STILL NEED TO DISCLOSE ANY OF THE FOLLOWING THAT applies.

Do you have any of the following:

• Surgical Implants – Electrically, Magnetically or Mechanically Activated

If so, where? Do you have an implant card? When was it implanted?

• Continuous Glucose Monitor and/or Insulin Pump
• Penile Implant
• Removable Heating Aids (Must be removed prior to entering MRI Suite)
• Neurostimulator (Tens-Unit)
• Holter Monitor
• Shunts, stents, filter, or valves
  • Location:
  • Type:
• Metal chips, foreign body or surgical device in eyes
• Occupations with exposure to metal fragments
• Metallic foreign bodies / Shrapnel / If so, Where?
• Metal rods, metal plates, pins, screws, nails or clips
• Aortic, brain, or carotid clips
• Harrington rod
• Prosthesis – Type:
  • Surgery date:
  • HIP REPLACEMENT Surgery
• Weight/Obesity

***If the patient answered yes to the above, there must be further discussion with the diagnostic group to ensure the ability to have a 3MRI. ***