Healthcare Imaging Document

HEALTHCARE IMAGING DOCUMENT

Patient Name:   Date of Birth:   Gender:

Phone:   Medical Record/Patient ID:   Emergency Contact:

Imaging Order

Ordering Provider:   Provider ID/NPI:

Body Part/Region to be Imaged:   Clinical Indication/Diagnosis:

Urgency: Routine ASAP STAT   Requested Exam Date:

Insurance / Billing

Policy/ID Number:   Group Number:   Subscriber (Name):

Medical History / Safety Screening

Known Allergies:   History of contrast reaction: Yes No

Renal Function / Most Recent eGFR or Creatinine:

Pregnant or breastfeeding: Yes No Unknown

Contrast, Sedation and Administration Consent

I authorize administration of the following as needed for the ordered exam (check all that apply):

Risks and possible complications include, but are not limited to: mild to severe allergic or anaphylactic reaction to contrast requiring treatment; contrast extravasation at the IV site leading to pain or local tissue injury; contrast-induced nephropathy in patients with impaired renal function; nephrogenic systemic fibrosis following certain gadolinium agents in patients with severe renal impairment; sedation-related respiratory or cardiovascular depression; infection at IV site; and rare unforeseen complications. I acknowledge that the ordering provider has explained the nature and purpose of the examination and the major risks and alternatives. I understand that no guarantee has been made as to the results.

I understand that I have the right to refuse all or part of the procedure, including contrast or sedation, and that refusal may affect diagnostic accuracy. If I decline elements of the exam, I accept responsibility for any resulting limitations in diagnostic information.

HIPAA & Disclosure Authorization

I acknowledge receipt of the facility's privacy practices and understand that protected health information related to this exam may be used and disclosed for treatment, payment, and healthcare operations as permitted by law. I authorize release of imaging records and reports to the ordering provider, consulting physicians, and entities involved in my care or payment for care.

Authorization Expiration: (If left blank, authorization is valid for the current episode of care.)

Patient Certifications

By signing below I certify that: the information I have provided is accurate to the best of my knowledge; I have had the opportunity to ask questions about the exam, alternatives, risks, and expected benefits; I consent to the performance of the ordered imaging procedure(s) and related care checked above; and I consent to administration of contrast and/or sedation if indicated and authorized above. I understand instructions given regarding preparation and follow‑up.

Sign Now