Consent And Release For Mammography Services For Patients With Breast Implants printable pdf download

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2700 Stewart Parkway, Roseburg, OR, 97471

541-677-4418

CONSENT AND RELEASE FOR MAMMOGRAPHY SERVICES

FOR PATIENTS WITH BREAST IMPLANTS

THE UNDERSIGNED hereby authorizes Mercy Medical Center (MMC) – consulting Radiologists,

technologists, and associated staff working under the direction of MMC to treat and provide

mammography services to:

Patient Name:________________________________________________________________________

I understand that breast implants pose a special situation for the techniques in mammography and

require a special type of exam that includes more pictures than a mammogram done on women without

implants. This is because the implant obscures some of the breast tissue and can make interpretation

more difficult. In most cases, the implant will be gently moved back and out of the way. Other films will

include the implant.

I understand that care will be exercised to reduce the risk of any adverse event. I understand the need

for breast compression during the course of obtaining a mammography study. I understand that no

result of this mammography study can be fully predicted, guaranteed or assured. I understand that no

guaranty is made as to the outcome of this mammography study. I further state that all questions I have

raised with respect to the proposed mammography study have been answered to my satisfaction.

I certify that the procedure(s) have been fully explained to me. I expressly waive any claim that I may

have against MMC, their physicians, technologists, and associated staff working under their direction

and hold said entities and persons harmless from any and all liability related to the rupture of breast

implants during the course of professionally administered mammography services.

I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING CONSENT AND RELEASE, AND I GIVE MY

CONSENT. THIS STATEMENT OF CONSENT AND RELEASE IS SIGNED OF MY FREE WILL.

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___________________________________________________________

Date

Signature of patient or legal guardian

___________________________________________________________

Relationship, if other than patient

__________

____________________________________________________________

Date

Witness

Consent And Release For Mammography Services For Patients With Breast Implants