Procedure Details: Your doctor has requested that you undergo a Nuclear Medicine diagnostic procedure. This type of imaging uses very small amounts of radioactive materials to diagnose and evaluate medical conditions.

Procedure Description: During the procedure, a small amount of radioactive substance (radiopharmaceutical) will be introduced into your body by injection or orally. This substance will then be taken up by the organs being evaluated and will emit small amounts of radiation which is detected by a specialized camera to create images of your internal organs or tissues. The amount of radiation used in this procedure is minimal and generally considered safe for yourself and others around you. The procedure is usually non-invasive and well-tolerated by most patients.

Some exams range from 30 minutes to 4 hours and may require you to return to the facility for additional, secondary or follow-up imaging.

Potential Risks:

While the amount of radiation is low, it may still carry some risks, especially for pregnant or breastfeeding women.

Possible side effects include:

1. Allergic reactions to the radiopharmaceutical.
2. Discomfort at the injection site.
3. Risk of radiation exposure, though minimal.

If you are pregnant, planning to become pregnant, or breastfeeding, please inform the physician and technologist, as this may affect the decision to proceed.

WAIVER & CONSENT

• I, the undersigned / confirmed, have been informed of the nature, purpose, potential risks, and benefits of the nuclear medicine procedure. I understand that while the procedure is generally safe, there are inherent risks involved, and I agree to proceed with the procedure.
• I consent to the use of the radioactive substance as described and understand that a qualified medical professional will administer and monitor the procedure.

Witness Confirmation

By clicking the "Confirm" button, you acknowledge that Apex Radiology has electronically witnessed this consent form. The date and time of submission are recorded and securely stored as part of your medical record.