CT for Low Dose Lung Screening_Merged Forms

  • CT for Low Dose Lung Screening Patient Forms

  • Patient Registration Form

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Complete below for patients under 18

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • How did you hear about us? (Please check all that apply)

  • Patient Consent Form

  • My physician has referred me for an*

  • I understand that:

    • The practice of medicine is not an exact science and no guarantee can be made as to the results that might be obtained from this procedure.
    • Complications can occur. By consenting to this exam, I hereby consent to the necessary medical or surgical actions of the physician and/or colleagues, medical/surgical; whomever they choose to consult with to take
      appropriate actions in regard to this procedure should any complications occur during my visit.
    • MedRVA Imaging may include consent at satellite offices under common ownership.

  • Patient Financial Responsibility

    I understand my financial responsibility and I guarantee payment for all charges not covered by my insurance, all applied deductibles and co-pays, within 30 days of receiving a statement.

    Medicare Patients

    I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to MedRVA Imaging.

    I, the undersigned, authorize MedRVA Imaging to use and disclose my information for the purposes of treatment, payment, and healthcare operations. A photocopy of this consent shall be considered as valid as the original.

     I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

  • Patient Attestation

    If a patient is a minor or has a legal guardian, the parent or guardian must sign for consent.
  • Date
     - -
  • Date
     - -

  • CT Patient History

  • Sex Assigned at Birth*
  • Gender identity (optional)
  • Are you currently pregnant or is there any chance you could be pregnant?*
  • Date of Last Menstrual Cycle
     - -

  • Medical History

  • Have you had any cardiac procedures?*
  • Have you ever been diagnosed with cancer?*
  • Do you now or did you ever smoke?*
  • Did you injure the area of interest?*

  • Screening Questions

  • Do you have any electronic medical devices? Ex: Pacemaker, Defibrillator, Neuro-stimulator, Retinal implant, Insulin pump, Cochlear implant, etc.*

  • Patient Attestation

    If a patient is a minor or has a legal guardian, the parent or guardian must sign for consent.
  • Date*
     - -
  • Date
     - -

  • Patient Smoking and Lung History

  • Insurance Type
  • Date of Birth:*
     - -
  • Smoking Status*

  • Smoking History

    Tell us how many packs per day you have smoked and for how many years. This may have varied for you over the years. Ex: 1 pack a day for 10 years and 2 packs a day for 20 years. We will use this to calculate your pack/year history. (Must have 30 pack/year history to qualify for screening)
  • Pack-years = packs per day x years smoked

  • Recent Symptoms

  • Do you have any of the following symptoms?*
  • Have you had a chest CT in the last 12 months?*
  • Did your physician discuss the risks and benefits of the lung cancer screening and ways to quit smoking?*

  • Personal History

  • Check All That Apply to You (Checking any of these boxes does NOT disqualify you from screening.)

  • Substance Exposure

  • Check All That Apply to You (Checking any of these boxes does NOT disqualify you from screening.)
  • Family history of lung cancer?*

  • Patient Attestation

    If a patient is a minor or has a legal guardian, the parent or guardian must sign for consent.
  • Today's Date*
     - -
  • Today's Date
     - -
  • Should be Empty: