CT Form

Please do not leave any blank. Fill out form completely.
NOTE

If you haven't already done so, please don't forget to accomplish the Release Form. Click on the link below to open the form in another window.

Patient Release Form

Some X-ray and CT examinations may expose the uterus. To avoid unnecessary fetal exposure in the event of pregnancy, the last 10 days immediately following menstrual period are generally considered safest for X-ray /CT examinations.

Have you had your ovaries removed? If yes, please indicate

Have you had any surgery related to this area? *

Have you had other surgeries? *

Have you had a prior diagnostic imaging study or examination? (MRI, CT, Ultrasound, X-ray, etc.) *

Do you have or have you had any of the following *
Please list any other medical conditions not listed above:

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I attest that the above information is correct and to the best of my knowledge. I read and understand the contents of this form and had the opportunity to ask questions regarding the CT examination.

Technologist Section
CONTRAST CONSENT

Your referring physician has ordered CT IV contrast enhancement to obtain more diagnostic information for the brain, chest, neck, abdomen, pelvis or other area of your body. As for the abdomen and pelvis, we will also have you drink oral contrast. The oral is for the GI tract and the IV is to look at blood vessels. The oral contrast you drink by mouth and the IV is put into the vein. In very rare cases, some patients have been known to have an allergic reaction to the IV contrast (medications are on hand to treat these conditions should they occur). In some very rare cases of those patients having a reaction, death may occur. Your technologist or radiologist will be happy to answer any questions you may have about this exam.

Patient Information Consent Form

Please initial lines 1-5
1.

It is understood that the diagnostic procedure(s) ordered by my physician will be performed by Global Imaging and do hereby authorize and consent to such service.

2.

I hereby authorize Global Imaging to release any medical information regarding the services performed to my personal physician, insurance company, and or employer (in the event of a worker’s compensation injury).

3.

A quote of benefits and/or authorization does not guarantee payment from your insurance companies. It is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. The undersigned hereby agrees to pay all charges not covered by the health nsurance company. Any balance not paid within 90 days after the date of service will be considered in default unless financial arrangements have been made with the business office.

4.

I acknowledge I have read and agree with the HIPAA policy. If for any reason I am unable to pick up my personal records, I understand Global Imaging office policy requires proof of family/friend identity to release my information.

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or otherwise as permitted by such regulations.

A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR THIS PURPOSE.

5.

I consent to receive text messages and emails from Global Imaging, LLP. I understand that this request to receive emails and text messages will apply to all future appointment reminders and updates.

I, the undersigned, have read the above and authorize the staff of Global Imaging to disclose such information as herein contained.