UCI Fetal MRI Study

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/2000)

City and State

Contact for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Can you comfortably lie in the MRI for one hour?

Yes No

Are you willing to schedule two research visits?

Yes No

What is your due date?

Format: Month/Day/Year (e.g., 01/15/2026)

How many weeks pregnant are you?

Is this a singleton pregnancy?

Yes No

Has the fetus been diagnosed with a congenital heart defect (CHD)?

Yes No

Do you have any non-removable metallic bodily implants? (e.g., piercings,pacemaker, stent, cochlear implants, plates, shrapnel)

Yes No