Pregnancy Waiver for X-Ray
Benefits of procedure:
Non-invasive, quick, and effective for evaluating bone structures, detecting fractures, and diagnosing lung conditions.
Risks of procedures:
Radiation from an x-ray can affect pregnancy, particularly during the early stages when the developing fetus is most sensitive to environmental factors, even though the amount of radiation from a single diagnostic x-ray is typically low and is considered safe.
Please answer the following questions below:
2. Are you or is it possible that you might be pregnant?
3. Are you on birth control?
4. If you're not using birth control, have you had sex since your last period that could result in pregnancy?
Acknowledgment and Consent:
I, understand that X-ray procedures involve the use of radiation, which may pose a potential risk to an unborn child. I acknowledge the following:
- My healthcare provider has informed me that radiation from this diagnostic x-ray may harm a fetus if I am or could be pregnant. If I suspect or know that I am pregnant, I understand the risks involved.
- I consent to proceed with the diagnostic x-ray, acknowledging the risks involved, and waive any liability related to the use of x-ray radiation.
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.