X-Ray History and Screening Form

Complete this before your appointment and your provider can be better prepared during their time with you.

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

Informed Consent For X-ray

You have the right to be informed about the diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you may choose to give or withhold your consent to the procedure. If you are pregnant or think that you may be pregnant, please inform the technologist at once. Your physician has requested that we perform x-rays to obtain additional information. This is a diagnostic test that involves x-ray images and a computer to produce an image of internal body parts.
Your physician believes an x-ray to be the best diagnostic test for you, considering your symptoms and condition. The benefit of this exam is to assist your physician with a diagnosis.

Visitor Screening Questionnaire

Please review to ensure the details are correct before completion.

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