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Consent for Evaluation using GE Dexa Scan

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.






First Participant's Name
First Name*
Last Name*
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First Participant's Date of Birth*
Date of Birth
First Participant's Height & Weight
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First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Second Participant's Height & Weight
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Third Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Third Participant's Height & Weight
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Fourth Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Fourth Participant's Height & Weight
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Fifth Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Fifth Participant's Height & Weight
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Sixth Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Sixth Participant's Height & Weight
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Seventh Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Seventh Participant's Height & Weight
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Eighth Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Eighth Participant's Height & Weight
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Ninth Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Ninth Participant's Height & Weight
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Tenth Participant's Name
First Name*
Last Name*
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Participant's Date of Birth*
Date of Birth
Tenth Participant's Height & Weight
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Parent or Guardian's Email Address
Email*
Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Height & Weight
Enter your current Height & Weight
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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