X-Ray/CT Imaging Consent Form (Women)

X-Ray/CT Imaging Consent Form (Women)
Patient No:
The radiation used in X-Ray/ CT may be harmful to an unborn child. To help prevent the accidental irradiation of an unrecognized pregnancy, and in accordance with national standards, we required the following information from female patients of childbearing age. If any of the information below indicated even the remote possibility of pregnancy, your referring medical officer/physician will be asked to order a urine or serum pregnancy test prior to any imaging.

Please answer the following questions:

	Yes	No	Unsure
Are you, or is it possible that you might be pregnant?
Are you currently breastfeeding?
Method of Birth Control
If you are not currently on birth control, have you had sexual activity since your last menstrual period that may put you at risk for pregnancy?

I, (patient or responsible party) First Name Last Name have been fully informed of the risks involved in radiating a first trimester pregnancy and assume the responsibility for any consequences from the procedures I am about to have. I also will not hold Halimatu Musa Hospital, responsible for any potential harm to my unborn child or myself.
Patient Signature

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