Consent to X-RAY Exam

Please review the form below

X-RAY EXAMINATION CONSENT FORM

I consent to these diagnostic x-ray procedure(s) that my Doctor of Chiropractic at Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic, considers necessary or advisable in the course of my health care. I understand the nature and purposes of these procedure(s) the risks involved, and the possible consequences of not consenting to the procedure(s).

Full Name *

Today's Date

Date of Birth

If minor, Full Name of Parent or Legal Guardian

Minor *

Yes
No
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Relationship to minor?

__________________________________________________________________________________________

FEMALE PATIENTS ONLY**

X-ray examinations may expose the uterus. In order to avoid unnecessary fetal exposure in the event of a pregnancy, the 10 days immediately following the onset of the menstrual period are generally considered safest for x-ray examinations.

I am pregnant?

Yes
No
I don't know
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Date of last menstrual cycle?

I am postmenopausal.

Yes
No
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I have had a hysterectomy.

Yes
No
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I acknowledge the potential risk of radiation exposure during pregnancy or if there's a chance of being pregnant, which could harm the fetus. Nevertheless, I am aware that the chances of such harm are minimal, and my physician deems the information from this test beneficial for my well-being. Hence, I would like to proceed with the x-ray examination at this time.

Please initial, indicating you understand the above statements. *

Your Initials

__________________________________________________________________________________________

Patient / Guardian Signature

Clear

Signature of Witness

Clear

Patient/Guardian Full Legal Name

Witness Full Name

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