Healthcare Scan Waiver

HEALTHCARE SCAN WAIVER

Patient Identification

Patient Name:

Date of Birth:    Gender:

Insurance Information

Relevant Medical History

Scan Details and Consent

Intended Scan Type (check all that apply):

MRI    CT    X‑Ray    Ultrasound    PET    Other:

The patient is informed that the procedure involves capturing diagnostic images for evaluation and that the ordering clinician has determined the anticipated medical benefit outweighs the risks. Risks may include, but are not limited to, allergic reaction to contrast agents, exposure to ionizing radiation (for CT/X‑ray), discomfort from confinement or noise (for MRI), and rare risks associated with sedation or intravenous access.

I acknowledge that the provider has explained the purpose, nature, and risks of the proposed imaging study and available alternatives, including the option to decline the procedure and the medical consequences of such refusal.

I acknowledge receipt of the risk/benefit information and have had an opportunity to ask questions.

Contrast Media and Sedation

Certain scans may require intravenous contrast or oral contrast to enhance diagnostic quality. Contrast administration carries risks, including allergic reaction and renal effects.

I consent to administration of contrast material as clinically indicated.

Sedation may be recommended for claustrophobia or inability to remain still. Sedation carries additional risks and requires separate informed consent where applicable.

I consent to sedation if required for the safe and effective completion of the scan (administration and monitoring per facility policy).

Contraindications and Special Considerations

Do you have any of the following? Check all that apply:

Metal implants, pacemaker, or electronic implant    Aneurysm clip or vascular implant    Neurostimulation device

Are you pregnant or is there a possibility you may be pregnant?

Yes    No    Unknown

Use of Images, Privacy and Release

I authorize the use of my diagnostic images and related information for my clinical care. I further authorize that de‑identified images and data may be used for teaching, quality improvement, and research in accordance with applicable privacy protections.

I consent to de‑identified images and data being used for teaching/research.    I consent to identifiable images/data being used only with additional written authorization.    I decline use of my images for teaching/research purposes.

By signing below, I authorize the facility and its staff to perform the indicated imaging procedure and agree to hold them harmless for ordinary risks inherent to the procedure. I understand that the practice will exercise reasonable care and clinical judgment in providing care and that unforeseen complications may occur. I release the facility and its clinicians from liability for complications arising from the procedure except for negligence or willful misconduct.

Authorization Duration and Revocation

This authorization is valid for the imaging procedure(s) described above and associated care until the earlier of the date of the procedure or the expiration date specified below. I understand I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

Sign Now