Diagnostic X-Ray Patient Forms

Patient Consent Form
My physician has referred me for an*

MRIX-RayCTDEXA
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.
Patient Signature
Date

MonthDayYear
Parent/Guardian Signature
Date

MonthDayYear
Should be Empty:

Diagnostic X-Ray Patient Forms

Patient Registration Form

Complete below for patients under 18

Patient Consent Form

Patient Attestation