midlandschiropractic.com - X-Ray Consent Form

X-RAY CONSENT FORM
Patient Name

First NameLast Name
PLEASE ANSWER THE FOLLOWING QUESTIONS (FEMALES ONLY)
1. Are you pregnant or any chance you may be?

YesNo
2. Date of the start of your last period.

MonthDayYear
Date
3. Are you on any type of birth control?

YesNo
4. Are you trying to get pregnant?

YesNo
Your signature indicates that you have read and answered all of the above questions accurately and accept all responsibility associated with exposure.
Patient Signature

Clear
X-rays are needed to properly diagnose your condition. By signing below, I consent to having the diagnostic x-rays performed.
Patient Signature

Clear
Should be Empty:

X-RAY CONSENT FORM