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Scarsdale Imaging, Inc.Patient Name:________________________ DOB: PREGNANCY RELEASE FORM As a female of the childbearing age, you must be aware that harm or damage may occur to any unborn fetus during certain radiological procedures performed here at Scarsdale Imaging, Inc. Therefore, if you are pregnant, or think you might be pregnant, all precautions must be taken to prevent harm to the unborn fetus, which typically includes not preforming any XRAY, CT, or MRI procedures on the pregnant mother. In order to protect you, and prevent such potential harm, it is required that you provide accurate and truthful information about all pregnancy related information, including the following: o I am on birth control Type__________________________________ (condoms are no considered a reliable form of birth control) o I have not been sexually active o I am not pregnant: Last menstrual period?______________________ o I am pregnant I attest that all the information that I have provided to Scarsdale Imaging, Inc. is truthful and accurate, if any such information is not accurate, I will hold all claims of damages of any type (this expressly includes claims for negligence or gross negligence) arising from any alleged har, to an unborn fetus or any harm to me as a result of miscarriage and/or harm to the unborn fetus. If I believe that I am pregnant or might be pregnant, I understand that it is my obligation to serum (blood) pregnancy test before any radiological examination performed by my PCP. Date:______________________________ Time:___________________am/pm Signature of Patient or other person legally authorized to consent for patient Relationship to Patient For Office use Only: Witness name 11034 Scarsdale Blvd. Suite A Houston, TX 77089 Scarsdale Imaging, Inc.Patient Name:________________________ DOB: Formulario de Embarazo Como una mujerde laedad fértil, debe ser consciente de quelos daños y perjuiciospuedenoccurea cualquierfetodurante ciertos procedimientosradiológicosrealizadosaquí enScarsdaleImaging, Inc.Por lo tanto, si usted está embarazadao cree quepodríaestar embarazada, todas las precaucionesdeben tomarsepara evitardaño al fetopor nacer, que por lo generalnoincluyepreformacióncualquier procedimientoRADIOGRAFÍA, CT, oMRIen la madreembarazada. Con el fin deproteger austed,yevitar ese dañopotencial, se requiere queusted proporcioneinformación precisa yveraz sobretoda la informaciónrelacionada con el embarazo, incluyendo las siguientes: o o o o Estoy encontrol de la natalidad Tipo:_______________________ No hetenido relaciones sexuales No estoyembarazada: último períodomenstrual?_______________ Estoy embarazada Formmang thai Là mộtphụ nữtrong độ tuổisinh đẻ, bạn phải nhận thứcrằngtổn hại hoặcthiệt hạicó thể xảy ravới bất kỳthainhitrong quá trìnhlàm thủ tụcphóng xạnhất địnhthực hiệnở đây tạiScarsdaleImaging, Inc.Vì vậy, nếubạn đang mang thai, hoặc nghĩ rằng bạncó thể có thai, tất cả cácbiện pháp phòng ngừaphảiđược thực hiện đểngăn chặn thiệt hạicho thai nhitrong bụng, mà thườngbao gồm khôngtạo hình trướcbất kỳthủ tụcXRAY, CT, MRIhoặctrên bà mẹmang thai. o o o o Tôivề kiểm soát sinh: Loại:__________________________________ Tôi đã khôngquan hệ tình dục Tôikhông có thai: Bài chu kỳ kinh nguyệt?_____________________ Tôi đang mang thai Date:______________________ Time:________________am/pm Firma delpaciente otutor legal Chữ kýcủabệnh nhân hoặcngười giám hộpháp lý Relación con elpaciente Mối quan hệ vớibệnh nhân For Office use Only: Witness name 11034 Scarsdale Blvd. Suite A Houston, TX 77089