Healthcare ALARA Document

Healthcare ALARA Document

Patient Information

Patient Name:   Date of Birth:

Medical Record Number:   Gender: Male Female Other

Procedure and Clinical Information

Urgency: Routine Urgent Emergent

Radiation Dose Justification and Optimization

Clinical justification provided by ordering clinician and reviewed by imaging staff: Confirmed

Pediatric patient consideration: Yes   If yes, weight (kg):

Pregnancy status confirmed: Pregnant Not pregnant   If pregnant or unsure, date of last menstrual period:

Contrast and Allergy Information

Intravenous contrast required for exam: Yes No

Risks, Benefits, Alternatives and Patient Rights

I acknowledge that the clinician has explained the medical need for the procedure, the expected benefits, and the reasonably foreseeable risks associated with ionizing radiation exposure, including but not limited to a small increased risk of cancer over my lifetime.

Alternatives to the requested procedure, when available and clinically appropriate, have been discussed (for example: ultrasound, MRI, non-radiating modalities, or deferred imaging). I have had the opportunity to ask questions and these have been answered to my satisfaction.

I understand that dose will be maintained As Low As Reasonably Achievable (ALARA) consistent with diagnostic objectives and that I may decline or withdraw consent at any time prior to the procedure without penalty to my ongoing medical care, except as otherwise required by law.

Patient acknowledgment of discussion on risks, benefits and alternatives: I acknowledge

Privacy and Release of Information

I authorize the release of necessary clinical information and images to the ordering clinician, consulting clinicians, insurers, and other health care professionals involved in my care for purposes of treatment, payment, and quality assurance. I understand that my health information will be handled in accordance with applicable privacy laws and facility policy.

Patient acknowledgment of privacy disclosure: I acknowledge

Certifications and Notices

By signing below I certify that I have read or had read to me this Healthcare ALARA Document, that the information I have provided is accurate to the best of my knowledge, and that I give informed consent for the above-referenced procedure. I understand the facility and clinicians will employ ALARA principles to minimize radiation exposure consistent with obtaining diagnostically adequate images.

I authorize the performance of the procedure and any reasonably necessary ancillary procedures associated with the imaging study. I understand that staff will document technique and dose parameters in the medical record and that images and reports will become part of my permanent medical record.

Sign Now