Consent and Release for Diagnostic X-Ray during Pregnancy

Procedure Name

Form Sections

Section 1info grid

Imaging Facility Name

Ordering Physician

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Estimated Gestational Age

Planned X-Ray Procedure

Section 2text block

Section 3list block

Section 4text block

Section 5list block

Section 6text block

Section 7text block

Section 8text block

Section 9text block

Section 10signature block

Patient Signature

Attending Physician / Radiologist Signature

Consent and Release for Diagnostic X-Ray during Pregnancy

Patient and Facility Information

Imaging Facility Name

Ordering Physician

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Estimated Gestational Age

Planned X-Ray Procedure

Nature and Purpose of the Procedure

This document records informed consent for a diagnostic X-ray exam during pregnancy. An X-ray is an imaging study that uses a low dose of ionizing radiation to produce pictures of inside the body. The clinical team has determined that this exam is medically necessary to diagnose a maternal condition that requires immediate care. The clinical team will use specialized shielding protocols to minimize fetal exposure.

Material Risks and Potential Complications

Fetal radiation exposure: diagnostic X-rays are kept at the lowest possible dose (typically well below 50 mGy), where the statistical risk of fetal harm is extremely low.

Theoretical risks of radiation exposure include a minor increase in the risk of childhood leukemia or developmental anomalies, depending on gestational age.

Clinical shielding: lead or lead-equivalent aprons will be placed over the patient's abdomen to block scatter radiation.

[Insert additional radiologic risk calculations as provided by the medical physicist here]

Expected Benefits

Expected benefits include the rapid and accurate diagnosis of maternal medical conditions (such as pulmonary infection or fracture), permitting immediate treatment and protecting both maternal and fetal health.

Reasonable Alternatives

Non-ionizing imaging alternatives, including ultrasound (US) or Magnetic Resonance Imaging (MRI) without contrast.

Postponing the diagnostic imaging until after the delivery of the child.

Refusing the scan and accepting the clinical risks of an undiagnosed maternal condition.

Financial Responsibility and Assignment of Benefits

I authorize the release of any medical information necessary to process my insurance claims. I understand that I am financially responsible for all charges not covered by my insurance plan, including deductibles and co-payments.

No Guarantees

I acknowledge that the practice of medicine is not an exact science, and I understand that no guarantees have been made regarding the outcomes of this diagnostic test or treatment.

Right to Revoke Consent

I understand that my participation is voluntary and I may revoke this consent at any time before the test or procedure is fully executed, without affecting my future medical care.

Patient Acknowledgment

I certify that I have read and understand this consent form. I have been given the opportunity to ask questions, and all my questions have been answered satisfactorily.

Signatures and Verification

Patient Signature

Attending Physician / Radiologist Signature

Document ID: CC-PENDING

CONSENTCOLLECT