Paediatric Medical Imaging Consent Form

Paediatric Medical Imaging Consent Form
Patient No:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
1. Details of proposed radiological investigations
I have explained the procedure to the person with parental responsibility for the child, or accompanying member of staff if that individual is attending with the child, including:

• When and where the examination will take place (if known)
• Who will be present and who will take the images
• Requirement for child to be kept still and possible methods
• Nature of images to be acquired, for example, head CT scan, X-ray images etc.
• Need for follow-up imaging
• Process and timescale for results
• Possible further radiological examinations etc.
Additional Information
The reasons for the radiological investigation(s)
Any risks associated with the investigation(s)
Signature of medical doctor

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Name

First NameLast Name
Date

MonthDayYear
Date
2. To be completed by the interpreter (if present/applicable):
I have, to the best of my ability, accurately communicated the information provided by the doctor to the person with parental responsibility and relayed any queries back to the doctor.
Signature

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Name

First NameLast Name
Date

MonthDayYear
Date
3. Special requirements:
The communication and access needs of the person with parental responsibility have been met, for example, language interpretation, sign language, access needs etc.(Circle which is appropriate).

No specific needs identifiedYes
If yes please state what was provided:
To be completed by the person with parental responsibility:
• I confirm that I have legal responsibility for this child.
• I agree to the radiological investigation(s) as described on this form being
performed on my child
• I confirm I have had the opportunity to have any questions about the procedure
answered.
• Should sedation or general anaesthetic be required I understand that I have the
opportunity to discuss the details with the anaesthetist. I understand an additional consent form will be required.
Signature

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Name

First NameLast Name
Date

MonthDayYear
Date
Relationship to child
6. Confirmation of agreement
I have;
• Confirmed the identity of the child with the person with parental responsibility
• Checked that they have no further questions.
• Checked prior documentation of consent
• Ensured that they give permission for the radiological examination(s) including any required immobilisation to go ahead
Signature (Radiographer)

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Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Paediatric Medical Imaging Consent Form

1. Details of proposed radiological investigations

2. To be completed by the interpreter (if present/applicable):

3. Special requirements:

To be completed by the person with parental responsibility:

6. Confirmation of agreement