Healthcare Body Scans Report

HEALTHCARE BODY SCANS REPORT

Facility Information

Patient Information

Patient Name:

Date of Birth:    Gender:

Primary Phone:    Secondary Phone:

Insurance Information

Policy Number:    Group Number:

Clinical Information and Indication

Scan Date:    Ordering Clinician:

Scan Protocol and Technical Data

CT    MRI    PET    Ultrasound    X-Ray

Equipment / Manufacturer:

Slice Thickness / Parameters:

Contrast and Agents

Contrast administered    If yes, agent and dose:

Sedation used    If yes, agent and dose:

Findings

Regions Examined (check all that apply)

Head    Neck    Chest    Abdomen    Pelvis    Extremities

Impression / Conclusion

The impression below summarizes the most salient positive and negative findings. This interpretation is based solely on the imaging study performed and should be correlated with clinical findings, prior studies, and laboratory data as needed.

Administrative and Legal Notices

This report constitutes a medical imaging interpretation prepared by qualified personnel. It documents observations made on the images provided at the time of the examination. Imaging findings may evolve with time and should be correlated with the patient's clinical presentation and additional diagnostic information. Incidental findings unrelated to the clinical indication are included for completeness; further evaluation may be required at the discretion of the treating clinician.

Confidentiality: Protected health information contained in this report is confidential and subject to applicable privacy laws. Disclosure is permitted only to authorized individuals or as required by law. By signing below, the patient acknowledges receipt of this report and the facility's privacy practices as provided at the time of service.

I acknowledge receipt of this report and that the results and recommendations were explained to me to the extent practicable at the time of service.

I authorize release of images and/or this report to other treating providers for continuity of care.

Personnel

Technologist Date:

Report Finalized Date:

Patient Certification and Signature

By signing below, I certify that I am the patient named above or the legal guardian/authorized representative. I acknowledge that I received a copy of this report, that the findings and recommendations were discussed with me to the extent possible, and that I understand that further evaluation may be recommended. I understand images and reports may be shared with other providers as necessary for my care unless I have explicitly withheld consent.

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