Healthcare Ultrasound System

HEALTHCARE ULTRASOUND SYSTEM — DIAGNOSTIC ULTRASOUND CONSENT AND AUTHORIZATION

Patient Information

Date of Birth:

Male Female Other / Prefer not to say

Insurance Information

Medical History

Procedure Details

Exam Type (select all that apply): Abdominal Pelvic Obstetric Vascular / Doppler Cardiac (echocardiography) Other:

Procedure Date:

Risks, Benefits, and Alternatives

Diagnostic ultrasound uses high-frequency sound waves to create images of internal structures. The procedure is non-invasive and does not use ionizing radiation. Benefits include providing diagnostic information to guide medical care. Risks associated with diagnostic ultrasound are minimal but may include transient discomfort from pressure of the transducer, rare localized thermal or mechanical effects, and limitations leading to incomplete or technically limited studies. Ultrasound imaging is operator-dependent; image quality may be affected by patient habitus, bowel gas, or patient inability to cooperate.

Alternatives to the proposed ultrasound exam may include other imaging modalities or clinical observation. I acknowledge that my physician explained alternatives, and I have had the opportunity to ask questions about the intended exam, risks, benefits, and alternatives. I understand that no guarantee can be made regarding diagnostic outcome.

I acknowledge that the risks, benefits, and alternatives have been explained and that I understand them.

Consent for Images, Recording, and Use

Images, video clips, and diagnostic information obtained during the ultrasound exam shall become part of the medical record. I authorize the facility to retain and use these images for clinical care and quality assurance. I also authorize release of images and reports to referring providers as necessary for my care.

Consent for clinical use and sharing with treating/referring providers Consent to de-identified use for teaching or professional education Decline de-identified use for teaching or education

Privacy and HIPAA Acknowledgment

I acknowledge that I have been informed of the facility's privacy practices with respect to protected health information. I understand that images and reports are part of my medical record and will be handled in accordance with privacy laws and facility policies.

I acknowledge receipt of the privacy notice and understand how my health information will be used.

Pre-Procedure Checklist

For accurate imaging, follow instructions provided by your clinician. Please confirm the following:

NPO / fasting as instructed Bladder full as instructed No special preparation required or followed

Are you currently pregnant? Yes No

Authorization and Limitations

By signing below I authorize the performance of the diagnostic ultrasound procedure described above. I authorize medically necessary images, recordings, and data collection during the exam. I understand that the facility and its personnel will exercise reasonable care in performing the exam and that unforeseen device malfunction or operator limitations may necessitate additional procedures or repeat imaging.

I release the facility and its personnel from liability for events arising from the performance of the ultrasound exam except for negligence or willful misconduct. I understand that this authorization will remain in effect until the date specified below or until I revoke it in writing, subject to rights already exercised in reliance on this authorization.

Expires on:

Patient Statement of Consent

I certify that I have read and understand this consent form, or it has been read to me in a language I understand. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I consent to the performance of the ultrasound exam and any routine, related procedures necessary for the completion of the exam.

I consent to the procedure and related imaging as described above.

Sign Now