Healthcare ALARA Form

HEALTHCARE ALARA FORM

This ALARA (As Low As Reasonably Achievable) Form documents the clinical justification, dose optimization measures, and patient acknowledgement for ionizing radiation exposure related to the indicated procedure. The patient (or legal guardian) affirms that the procedure has been explained, risks and benefits discussed, and reasonable measures to minimize exposure have been implemented consistent with professional radiation safety standards.

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Is the patient pregnant or possibly pregnant? Yes No Unknown

If pregnant, date of last menstrual period:

Procedure Details / Clinical Indication

Referring Clinician:    Urgency:

ALARA Justification and Dose Management

Clinical justification summary: the procedure is deemed medically necessary because .

Estimated effective dose (if available):    Estimated fluoroscopy time / exposure count:

Pediatric protocol applied: Yes No

Radiation Safety Measures / Shielding

Shielding provided and applied where appropriate:

Lead apron Thyroid shield Gonadal shield Lead eyewear

Acknowledgment and Consent

I acknowledge that the nature and purpose of the proposed procedure have been explained to me, including the expected benefits, material risks related to ionizing radiation exposure, and reasonable alternatives. I understand that radiation exposure, while minimized by established ALARA practices, may involve risk, including but not limited to tissue reactions or stochastic effects. I have had the opportunity to ask questions and have received answers to my satisfaction.

I consent to the performance of the above procedure and to the use of radiation as necessary for diagnosis or treatment under the ironclad principle of minimizing dose consistent with obtaining diagnostic quality images.

I acknowledge and consent as stated above.

I understand that I may withdraw consent at any time prior to or during the procedure by notifying the technologist or ordering clinician, subject to medical considerations and the clinician's professional obligation to advise regarding potential consequences of withdrawal.

HIPAA privacy acknowledgment: I acknowledge receipt of the facility's privacy practices and consent to release of clinical and imaging information to relevant treating providers for continuity of care.

Authorization valid until: (if left blank, authorization is valid for the date of service only)

Staff Verification (For Facility Use)

Additional facility notes:

Signature

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