By signing below, I ________________________________________, hereby acknowledge and consent to proceed with the performance of a comprehensive body composition test or diagnostic area specific bone density testing using a DEXA scan machine. I understand that the composition test may be used to determine my total body composition, which includes percent and distribution of body fat and lean mass. I also understand that no medical advice will be given following my test and any results that are provided do not constitute medical advice. If state or local regulations require, I represent that a licensed practitioner of the healing arts has been consulted and has approved your request for testing. I also acknowledge that I have read the body composition test information provided (DEXA Scan Information), and I understand that this test will be used to give me information that is more accurate than BMI (body mass index). I consent to the performance of this test on me so that I can understand either my baseline body composition or follow-up on a previous body composition test in order to implement or continue my medically supervised plan to improve my overall fitness level and/or health. DEXA scans pose a risk of potential minor levels of radiation exposure, however, DEXA scans are considered very safe but are not allowed for pregnant women. If you as a client have had a past issue with body dysmorphia, body dissatisfaction, disordered eating, or eating disorders, there might be greater risks. Dexa Body is NOT a medical facility, by completing a DEXA scan of your own free will, you ackowledge and accept all the above mentioned risks. Furthermore, you understand that no diagnosis or treatment plans will be given or be used to replace the guidance of a licensed medical provider. Follow-up with a medical provider is strongly encouraged. I accept any and all risks associated with the performance of this DEXA scan and agree to indemnify and hold harmless Dexa Body, Inc. and its officers, directors, agents and employees from and against any claims, damages, losses and expenses resulting from the performance of this test.
As a female patient, initialing below also reflects a confirmation of no current pregnancy As a patient, initialing below also reflects a confirmation of no recent barium exams or injections of contrast materials for any radioisotope scans.
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