Healthcare Radiation Safety Exam

Healthcare Radiation Safety Exam

This Radiation Safety Exam documents patient screening, clinical justification, and informed consent for the use of ionizing radiation in diagnostic or therapeutic procedures. The facility requires accurate disclosure of medical history, pregnancy status, and prior radiation exposure to minimize risk. In signing this form, the patient or authorized representative affirms the truthfulness of the information provided.

Patient Information

Insurance / Responsible Party

Medical History & Screening

Radiation Exposure History

Have you had previous diagnostic or therapeutic radiation (X-ray, CT, nuclear medicine, fluoroscopy, radiation therapy) within the last year? Yes    No

Pregnancy and Reproductive Health Screening

For patients of childbearing potential: Are you pregnant, suspect you may be pregnant, or currently breastfeeding?

Pregnant: Yes    No

If female, date of last menstrual period or estimated date of conception:

Use of reliable contraception: Yes    No

Procedure Information & Clinical Justification

Risks, Benefits, and Alternatives

The use of ionizing radiation has known benefits in diagnosis and treatment and carries potential risks including, but not limited to, an increased lifetime risk of cancer, radiation-induced skin injury for high-dose procedures, and adverse reactions to contrast agents when used. The anticipated clinical benefit of the ordered study is considered to outweigh the risks based on the stated clinical indication.

Alternatives to the proposed procedure including no imaging, ultrasonography, or magnetic resonance imaging may be appropriate depending on clinical circumstances. I have had the opportunity to ask questions and understand the risks, benefits, and alternatives as explained to me.

Consent, Privacy and Authorization

I authorize the performance of the above-described procedure(s) involving ionizing radiation. I authorize personnel to administer contrast agents if required for the procedure and to take any precautions deemed necessary for my safety. I understand that unexpected findings or complications may require additional procedures and I consent to such actions as clinically necessary.

I acknowledge that my medical information related to this procedure may be recorded and used for clinical care, quality assurance, regulatory reporting, and professional communication in accordance with patient privacy standards. I understand I may withdraw this authorization in writing prior to the procedure, except to the extent that actions have already been taken in reliance on this consent.

Technologist / Examiner Use

Patient Attestation

By signing below I attest that I have read and understand the information contained in this Radiation Safety Exam form; that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction; and that the information I have provided is true and complete to the best of my knowledge.

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