CONSENT FOR RADIO-IODINE TREATMENT AT A PRIVATE RESIDENCE

Statement of patient or person with responsibility for patient.

• I understand the information explained and discussed with me regarding my treatment with radio-active Iodine at my residence.
• I understand the precautions I must take to minimize the radiation exposure of other people.
• I give consent to be treated with radioactive iodine at my residence by a Nuclear Medicine Technologist, Apex Radiology, on the instructions of Dr.

IN HOSPITAL:

I have read and understood the information for patients admitted at a hospital. I understand the precautions I must take to minimize the radiation exposure of other people. I give my consent to receive radioactive iodine treatment.

WAIVER & CONSENT

For women of reproductive age:

• I confirm that I am not pregnant and that I will inform the staff If I become pregnant before I receive radioactive iodine treatment.
• I understand that I should not receive radioactive iodine treatment when I am pregnant, and I should avoid pregnancy for at least 6 months after receiving the radioactive iodine treatment.

For men:

• I understand that I should avoid fathering a child for at least 4 months after receiving the radioactive iodine treatment.

Payment:

• I hereby agree with the payment requirements for Radioactive Iodine Therapy to be administered by the medical staff of Apex Radiology.
• I clearly understand and accept that the medication to be administered is radioactive and will undergo radioactive decay if not administered in the time frame recommended. I clearly understand and accept that payment must be made in advance, and if I am unable to undergo treatment on the specified date, a refund may not be possible.

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.

Confirmation of Consent: (to be completed by health professional responsible for administration immediately before administration If the patient has signed the form in advance)

• I have discussed relevant written radiation protection advice for female patient. The patient confirmed she is not pregnant.
• Patient has no further questions and wishes to proceed with the procedure.