DEXA_Merged Forms-MedRVA Imaging

  • DEXA 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
     - -

  • DEXA Questionnaire

  • Date of Exam*
     - -
  • Gender assigned at birth*
  • Ethnicity*
  • Is there a chance you may be pregnant?*
  • Which is your dominant hand?*
  • Do you have any perceived height loss?*
  • Has a parent had a hip fracture?*
  • Do you drink more than 3 alcoholic beverages per day?*
  • Are you on any corticosteroids (e.g. Prednisone/Hydrocortisone)?*
  • Are you on long term Glucocorticoids? (Chronic)*
  • Do you have a family history of Osteoporosis?*
  • Do you have a history of fractures as an adult?*
  • Do you have Rheumatoid Arthritis?*
  • Do you have scoliosis?*
  • Do you take Calcium Supplements?*
  • Do you have secondary Osteoporosis (caused by specific diseases or medications)?*
  • Are you postmenopausal?*
  • Do you have any metal in your body?*
  • Have you had hip replacement surgery?*
  • If yes, which one applies?
  • Have you had lower back surgery?*
  • Have you had this examination previously?*

  • Patient Attestation

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