Healthcare C-arm Document

Healthcare C-arm Use & Radiation Consent Form

Patient Name:   Date of Birth:   Gender:

Patient Information

Insurance Information

Medical History

Pregnant or possibly pregnant: Yes No Unknown   If pregnant or uncertain, last menstrual period:

Procedure & C-arm Use Details

Equipment & Safety Checklist (To be completed by staff)

Radiation Safety Measures Implemented: Lead apron provided Thyroid shield Gonadal shielding Sterile drape used

Risks, Benefits, Alternatives, & Consent

I authorize the use of ionizing radiation via a C-arm image intensifier as deemed necessary by the treating physician and operating staff for the above-described procedure. I understand that this imaging modality involves exposure to ionizing radiation which carries risks including, but not limited to, increased lifetime risk of cancer, radiation-induced skin injury at high doses, and other tissue effects. The magnitude of risk is dependent on the duration and intensity of exposure and the body region imaged.

I acknowledge that the anticipated benefits include accurate visualization to assist diagnosis and/or guidance for treatment, improved procedural safety, and reduced need for additional procedures. Alternatives to fluoroscopic imaging, when available, such as ultrasound or non-ionizing imaging, have been discussed when clinically appropriate.

If contrast media is to be administered, I acknowledge that contrast-related risks, including allergic reaction, nephrotoxicity, and other adverse effects, have been explained. I have informed staff of all known allergies and my medical history relevant to contrast administration.

I understand that I may withdraw consent at any time prior to or during the procedure; however, withdrawal may limit the ability of the clinical team to provide recommended care. I consent to medical personnel operating equipment, positioning me, taking images, and performing any necessary immediate actions to ensure my safety in the event of equipment malfunction or medical emergency.

Privacy & Authorization

I acknowledge that the facility's privacy practices concerning my protected health information have been made available to me and that information related to my imaging exam will be documented in my medical record and may be shared with other treating providers as necessary for treatment, payment, and healthcare operations. I authorize release of images and reports to other providers involved in my care.

Authorization for release of information and this consent will expire on: unless earlier revoked in writing.

By signing below I certify that I have read or had read to me the above information, that my questions have been answered, and that I voluntarily consent to the use of C-arm fluoroscopic imaging and any indicated contrast administration as part of my care.

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