Healthcare Neurosonology Form

HEALTHCARE NEUROSONOLOGY FORM

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Insurance Information

Policy / ID Number:    Group Number:

Clinical Indication & Exam Ordered

Requested Exam Type (check all that apply):

Carotid Duplex    Transcranial Doppler (TCD)    Cerebral Venous / Sinus Study    Contrast-Enhanced Study    Other:

Laterality:    Requested Exam Date:

Medical History & Allergies

History of bleeding disorder:    Pacemaker, implant, or shunt present:

Female patients: Pregnant or suspect pregnancy:

Consent for Neurosonology Examination

I authorize the performance of the neurosonology examination(s) indicated above. The procedure will involve application of ultrasound transducers to the head, neck, and/or temporal windows, recording of Doppler signals, and capture of images. If contrast-enhanced techniques are indicated, contrast agents may be administered intravenously to improve diagnostic accuracy.

I understand the following reasonably anticipated risks and limitations: transient discomfort at the probe site, allergic or adverse reaction to contrast agents, inability to obtain diagnostic images due to anatomical or technical factors, and rare risk of infection or bruising at an IV site. I have been given the opportunity to ask questions and understand that no guarantee has been made regarding the results.

I understand I may withdraw consent at any time prior to or during the procedure without penalty, but withdrawal may prevent completion of the examination and could limit diagnostic evaluation by my physician.

Authorization Expiration Date (if different from date of signature):

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with the facility's privacy practices and understand that my medical information, including images and reports generated from this examination, will be used and disclosed for treatment, payment, and healthcare operations as permitted by law. I permit the release of findings to my referring physician and other treating providers involved in my care.

I consent to the use of de-identified images for education and quality assurance unless I explicitly withhold such use below.

Withhold de-identified image use for education/QA:

Authorization to Release Images & Reports

I authorize release of images and diagnostic reports to the following person(s) or entities (referring physician, family member, legal representative):

Examiner / Scheduling Use Only

Exam Start Time:    Exam End Time:

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