Healthcare Rad Document

Healthcare Rad Document

Patient Identification

Patient Name:    Date of Birth:

Gender:    Phone:

Emergency Contact

Insurance & Billing

Clinical Order / Study Requested

Ordering Physician:    Clinic/Dept:

CT    MRI    X‑ray    Ultrasound    Fluoroscopy    Nuclear Medicine    Other:

Scheduled Date:

Medical History & Allergies

Prior reaction to medical contrast: Yes    If yes, describe:

Chronic conditions (check all that apply):   Diabetes   Renal disease / dialysis   Thyroid disease   Cardiac disease

Pregnancy & Reproductive Status

Female of reproductive potential: Yes    Pregnant or suspect pregnancy: Yes    If yes, last menstrual period:

Consent for Radiologic Procedure, Contrast, and Associated Care

I hereby authorize and request the performance of the radiologic procedure(s) listed above. I authorize the administration of intravenous or oral contrast agents, local anesthetic, and administration of sedation or analgesic medications if ordered by the referring or supervising physician and administered by qualified personnel.

I understand that the purpose of the examination is to assist in diagnosis and treatment. The expected benefits include improved diagnostic information to guide my care. Reasonable alternatives and their expected results have been explained to me, including the option of declining the procedure and pursuing alternative testing or no testing.

I consent to IV contrast administration.
I consent to oral contrast administration.
I consent to procedural sedation/analgesia if required.
I consent to local anesthetic (e.g., for injections, line placement).

Risks, Complications & Alternatives

I acknowledge that no procedure is without risk. Potential risks include, but are not limited to: allergic or anaphylactoid reaction to contrast ranging from mild to severe (including death); nephrotoxicity resulting in impaired kidney function especially in those with preexisting renal disease; local pain, infection, bleeding, or nerve injury at injection sites; radiation exposure (for ionizing exams) with associated risk; complications from sedation such as respiratory depression; and the possibility that the procedure may not provide a definitive diagnosis. Reasonable alternatives have been explained.

If I have questions about risks, benefits or alternatives, I have had the opportunity to ask them and receive answers to my satisfaction.

Authorization for Use and Disclosure of Health Information

I authorize the release of imaging results, reports and related health information to the ordering provider, other treating providers, and as needed for treatment, payment and health care operations. I understand that my health information may be disclosed as necessary for interpretation of images, follow-up care, billing and legal requirements.

I understand that this authorization will remain in effect for the period specified below or until revoked in writing, except to the extent that action has already been taken in reliance on this authorization.

Acknowledgments

By signing below I certify that I have read (or have had read to me) and understand the information on this form, that the information I provided is true to the best of my knowledge, and that I have had the opportunity to ask questions. I understand I may withdraw consent at any time in writing, except to the extent actions have already been taken based on this consent.

I acknowledge receipt of the facility's privacy practices and consent to the use and disclosure of my protected health information for treatment, payment and health care operations as described above.

Interpreter/Witness present:

Patient Representative (if applicable)

If this form is signed by someone other than the patient, state your legal relationship and authority to sign:

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