Healthcare X-ray Document

Healthcare X-Ray Document

Facility Name:    Ordering Provider:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy/ID Number:    Group Number:

Clinical & Imaging Request

Requested Exam (check all that apply):

Chest    Abdomen    Extremity    Spine    Skull    Other

Date of Onset / Symptoms:    Prior imaging for this problem:

Medical History

Implanted Devices (check all that apply):   Pacemaker   IUD   Prosthesis   None   Other

Pregnancy & Contrast Considerations

Are you pregnant or is there a possibility you could be pregnant?   Yes   No   Unsure

Contrast material may rarely be required for certain studies. Have you had a prior reaction to contrast?   Yes   No

Consent, Risks & Authorizations

I authorize the performance of the radiographic examinations ordered by the ordering provider. I understand that X-ray imaging uses ionizing radiation and that exposure involves a small increased risk of harmful effects, including cancer, but that such risks are generally outweighed by the diagnostic benefit. I acknowledge that the technologist may adjust positioning and remove clothing or metallic objects as necessary for diagnostic quality.

I understand that contrast agents may rarely cause allergic or adverse reactions and that such agents will be used only if medically indicated; I authorize emergency treatment if an adverse reaction occurs. I have informed the staff of any known allergies and prior reactions.

I have the right to refuse or withdraw consent before the procedure is performed. Withdrawal of consent after imaging has commenced may limit diagnostic results and will be documented.

By signing below I consent to the imaging procedure(s) indicated, authorize release of images and reports to the ordering provider and other healthcare entities involved in my care, and authorize reproduction of images for diagnostic and treatment purposes. This authorization for release of images shall remain effective until unless earlier revoked in writing.

I acknowledge that I am responsible for any charges not covered by my insurance, including facility or professional fees related to this imaging procedure, and that billing will be submitted to my listed insurer.

I understand that clinical results will be communicated to the ordering provider and, where applicable, to the patient or legal guardian. I acknowledge receipt of the facility's privacy practices and consent to the use of my health information for treatment, payment and healthcare operations as required for this procedure.

Patient or Legal Representative hereby certifies that the information provided is true and complete to the best of their knowledge and that they have had the opportunity to ask questions about the procedure, risks, benefits and alternatives.

Acknowledgments:

I acknowledge the risk and benefit statement above.    I acknowledge receipt of the facility's privacy practices.

Additional Instructions / Notes

Sign Now