X-Ray Safety Questionnaire

"*" indicates required fields

11/07/2024

Name*

First Last

Email*

DOB*

MRN#*

Date of Injury or Accident

The following items may be harmful to you during your X-Ray scan or may interfere with the X-Ray examination. Please provide a “yes” or “no” answer.

Safety Question ( for women only): Any chance you are pregnant?

Yes

Remove jewelry or body piercings in the area of examination.

FACILITIES