X-Ray Consent Form (Men)

X-Ray Consent Form (Men)
Patient No:
I hereby authorize the performance of diagnostic x-rays. The medical officer has requested the x-rays for further diagnostic purposes. At this time I know of no other condition in which the taking of x-rays would further complicate.
Patient Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Consent taken by
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: