DEXA Consent

DEXA CONSENT FORM
Patient Name:*
Today's Date:*

MonthDayYear
Date
As part of your exam, a DEXA-Scan X-ray study will be performed to determine bone density and body composition. In the past 7 days, have you had any contrast studies (Barium, Contrast CT, Nuclear medicine)?*

YesNoDon't know
I understand that if I am pregnant and have x-rays taken, which expose my lower torso to radiation, it is possible to injure the fetus, and I should not undergo the scan.
Patient Initials:*
I am advising my doctor that:
I am pregnant

YesNoDon't know
I could be pregnant

YesNoDon't know
My menstrual period is late

YesNoDon't know
My last menstrual period began

MonthDayYear
Date
The DEXA-Scan will not be performed if you have answered "yes" to any of the above questions, or if there is a possibility of pregnancy. A voucher is available if you would like to have this procedure done within a year of your physical exam.

With full understanding of the above, and believing that I am not currently at risk, I wish to have the DEXA-Scan study performed.
Signature*

Clear
Today's Date:*

MonthDayYear
Date
Should be Empty:

DEXA CONSENT FORM