Limited Radiography Exam Eligibility Checklist Form
Please complete this checklist to determine your eligibility for a limited radiography exam. All information is required to ensure a safe and appropriate assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Purpose of Exam
*
Routine screening
Diagnostic follow-up
Injury assessment
Referral from provider
Other
Are you currently pregnant or is there a chance you could be pregnant?
*
Yes
No
Not applicable
Do you have any implanted medical devices or metal implants (e.g., pacemaker, joint replacements)?
*
Yes
No
Not sure
Have you had any radiographic imaging (X-rays, CT scans) in the past 12 months?
*
Yes
No
Not sure
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Pain or discomfort
Swelling
Limited movement
Fever or infection
None of the above
Do you have any known allergies to contrast agents or medications used in imaging procedures?
*
Yes
No
Not sure
Submit Eligibility Checklist
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