PREGNANCY CONSENT FORM

INFORMED CONSENT TO PROCEED WITH MRI PROCEDURE DURING PREGNANCY

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This consent is to inform you the Magnetic Resonance Imaging (MRI) procedure you are having today is at a possible risk to your unborn child/fetus. By signing this you are consenting to understanding all of the information below and have asked all questions needed to understanding the risks associated with the procedure.

To date, there are no reports of injury to children who underwent MR imaging before birth. While the number of patients scanned during pregnancy is small, with limited follow-up, in the past several years, numerous pregnant patients have undergone MRI with no ill effects. MR imaging of pregnant patients is carried out when the patient's physician has decided that the advantages of MRI outweigh the potential risks.

I , have read the above warning and understand the potential harmful effects to my unborn fetus. I consent to have this MRI procedure as prescribed by my physician. I acknowledge that I have been given ample opportunity to ask questions and that all questions have been answered to my satisfaction. Furthermore, I fully understand that I may refuse to have this MRI procedure conducted on me without any obligation to American Health Imaging, Inc. or any of its subsidiaries. Also, I understand that I may stop this MRI procedure at anytime during its process.

Furthermore, I fully agree that the risks described herein are risks that I am willing to accept. Also, I agree that I will hold harmless American Health Imaging, Inc. and any of its subsidiaries, owners, and employees should I, or my fetus, experience any negative effects from this MRI procedure.






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