Effective Date- This notice is in effect as of 4/15/2003
By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.
Patient Signature Date
X-Ray Questionnaire: For Women Only
Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your spinal condition. Should x-rays be necessary, we would like to confirm that you are NOT pregnant at this time.
1. There is a possibility that I may be pregnant at this time: Y/N
2. Yes, I am definitely pregnant: Y/N
3. No, I am definitely NOT pregnant: Y/N
4. I request that x-ray films not be taken because:______________________________
Date of last menstrual cycle: _______________________