Healthcare Mobile X-Ray Form

Healthcare Mobile X-Ray Form

Patient Information

Date of Birth:    Gender:    MRN/ID:

Insurance Information

Exam Details & Clinical Information

Order Date:    Ordering Phone:

Medical History

Pregnancy Screening

If female of childbearing potential: Is the patient pregnant? Yes No Unknown

If applicable, Date of Last Menstrual Period:

Consent for Mobile X-Ray & Authorization

I hereby authorize the mobile radiology technologist and supervising physician to perform the radiographic examinations and related imaging procedures as ordered by the ordering physician. I understand that ionizing radiation is used and that while the dose is minimized, there is a small increased lifetime risk of cancer. I have had an opportunity to ask questions and understand the risks, benefits, and alternatives, including the option to decline the exam. I acknowledge that clinical benefit is expected to outweigh the potential risk of radiation exposure in this case.

I authorize the release of images and pertinent radiology reports to the ordering physician, attending providers, and other healthcare entities involved in my care. I understand that my imaging records will be maintained in accordance with applicable privacy laws and the provider's privacy practices.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have been informed of my rights regarding the use and disclosure of my protected health information and that a copy of the provider's privacy practices has been offered. I authorize disclosure of imaging results to the ordering and treating providers as necessary for my care.

Technologist / Procedure Notes (for staff)

Sign Now