I consent to these diagnostic x-ray procedure(s) my doctor may consider necessary or advisable in the course of my health care. I understand that the above listed diagnostic x-ray procedure(s) have been ordered by my doctor and are to be performed at Maryland ENT Associates under the supervision of my physician. I understand the nature and purpose of these procedure(s) and the risks involved, and the possible consequences of not consenting to the procedure.

BLUE CHOICE & UHC HMO DO NOT COVER IMAGING OUTSIDE OF AN IMAGING CENTER!

When this procedure is medically advised:

I hereby authorize my doctor or his/her associates to perform diagnostic imaging. I understand and acknowledge the benefits and risks of the procedure(s) as explained above.   

I decline to have diagnostic imaging. I am aware that this procedure is recommended based upon my symptoms, physical exam and/or history. I understand that declining this procedure my lead to an incorrect or lack of diagnosis which may adversely impact my treatment and outcome. I understand the risks associated with refusing this procedure.   

FEMALE PATIENTS PLEASE INITIAL  
I recognize that if I am (or am unaware that I am) pregnant and have radiation, there is a possibility of injury to the fetus. However, I understand that the likelihood of such injury is slight and that my physician feels that the information to be gained from this examination is important to my health. I therefore wish to have this x-ray examination performed at this time.

PARENTS OF MINOR PATIENTS PLEASE INITIAL  
I am the parent or legal guardian of the below patient who is a minor. Maryland ENT Associates has requested x-rays for further diagnostic purposes. At this time I know of no other condition which the taking of x-rays would further complicate and give my permission for imaging procedure(s).

If you have any questions please do not hesitate to ask our staff or your Doctor for more information.

Patient Name  * 

Patient Date of Birth  * 

Patient/Parent Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date Signed *