Chest X-Ray & TB Testing

Chest X-Ray & TB Testing
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Who referring you to us?
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Are you affected by any of the following in the last 12 months? (Please check al that apply) Past/Present

The FluCommon ColdNausea/VomitingTuberculosisAny other illness
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PATIENT CONSENT TO X-RAY
I Name* authorize the performance of diagnostic x-ray examination on myself which Dr. Zwirn or the appropriate staff consider necessary or advisable in the course of examination and treatment.
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VERIFICATION OF NON-PREGNANCY

If Applicable - If this not pertain to you please put N/A
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This is to certify that to the best of my knowledge, I, Name* am not pregnant and that Dr. Zwirn or the appropriate staff has my permission to perform diagnostic x-ray examination. I have been advised that x-rays can be hazardous to an unborn child.
Date of last menstrual period:Date*
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CONSENT TO X-RAY A MINOR

If Applicable - If this does not pertain to you please put N/A
I authorize the performance of diagnostic x-ray examination of my child or ward which Dr. Zwirn or the appropriate staff consider necessary or advisable in is a the course of examination and treatment.
I, Parent/Guardian Name, authorize the performance of diagnostic x-ray examination of my child or ward which Dr. Zwirn or the appropriate staff consider necessary or advisable in the course of examination and treatment. The patient, Minor Name is a minor, Age of Minor years of age,
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Chest X-Ray & TB Testing

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PATIENT CONSENT TO X-RAY

VERIFICATION OF NON-PREGNANCY

CONSENT TO X-RAY A MINOR