Healthcare Radiology Draft

HEALTHCARE RADIOLOGY DRAFT

Patient Information

Date of Birth:    Gender:

Phone:    Emergency Contact:   Phone:

Insurance & Subscriber

Policy Number:    Group Number:

Subscriber Date of Birth:

Referring Provider & Clinical Indication

Facility / Clinic:    Phone:

Requested Date or Urgency:

Procedure & Imaging Order

Exam / Body Part:

X-ray    CT    MRI    Ultrasound

Nuclear Medicine    Interventional Radiology    Mammography    Fluoroscopy

IV contrast    Oral contrast    No contrast

Sedation or anesthesia required: Yes    If yes, provide details:

Medical History / Safety Screening

History of renal impairment, dialysis, or transplant: Yes    If yes, latest creatinine (if known):

Presence of implantable devices or metal that may affect imaging (e.g., pacemaker, aneurysm clips, cochlear implant):

Claustrophobia or inability to lie flat: Yes    If yes, explain:

Pregnancy Screening

To the best of my knowledge I am: Not pregnant    Pregnant    Possibly pregnant

If applicable, date of last menstrual period:    Pregnancy test required prior to procedure:

Risks, Benefits, and Alternatives

I acknowledge that the referring provider has explained the nature of the requested radiology procedure, its expected benefits, and reasonably foreseeable risks, including but not limited to: allergic reaction to contrast agents, nephrotoxicity in patients with impaired renal function, radiation exposure (for ionizing studies), and procedure-specific complications. I understand that alternative diagnostic options may exist and have had the opportunity to discuss alternatives with my provider.

By selecting the checkbox below I affirm that I have had the opportunity to ask questions and that those questions were answered to my satisfaction.

I acknowledge that risks, benefits, and alternatives were explained and I consent to the proposed imaging procedure.

Authorization to Use and Release Information

I authorize release of diagnostic images, radiology reports and relevant medical information to the referring provider, other treating providers, and to entities involved in my care or payment for services. I understand that medical images and reports may be used for teaching and quality assurance in a manner that protects my identity.

I authorize release of images and radiology reports as described above.

Authorization Period and Limitations

This authorization is valid for the imaging procedure(s) specified herein and for release of records related to those procedures. Unless earlier revoked in writing, this authorization will expire on the date below or upon completion of release of records for the specified procedures, whichever occurs first.

Patient Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that withholding or providing false information may increase the risk of adverse events. I consent to the performance of the radiology procedure(s) specified by the referring provider and authorize necessary clinical personnel to perform the procedure(s) and to administer contrast or sedation as indicated and ordered.

I have read, (or had read to me), and understand the above information and consent to the exam and associated releases as set forth in this form.

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