Consent Statement:

1) I, the undersigned, understand that an X-ray examination is a diagnostic tool used to visualize the internal structures of my body to assist in diagnosing and monitoring medical conditions. The procedure involves exposure to a controlled amount of radiation to capture the necessary images.

2) I, the undersigned, acknowledge that I have been fully informed about the X-ray examination recommended for me. I understand the purpose of the examination, the procedure involved, and the potential risks associated with radiation exposure. I have had the opportunity to ask questions regarding the X-ray examination and have received satisfactory answers.

3) I, understand that if I am pregnant, there is a risk of radiation exposure to the foetus, which can lead to potential health risks.

4) I, understand the risks of radiation exposure during pregnancy (if applicable) and accept responsibility for any consequences. I will not hold RxDx responsible for any potential harm to myself or my unborn child.

5) I, confirm that I have been informed about alternative diagnostic procedures, if applicable.

6) I, confirm that I have the right to refuse the examination, and such refusal may affect the quality of my medical care.

7) I, voluntarily consent to undergo the X-ray examination. I understand that I can withdraw my consent at any time before or during the procedure.