This document is my acknowledgement and consent to proceed with the performance of a comprehensive body composition test using a DEXA scan machine. I understand that this test is being 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, 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 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 understand that I am consenting to this test 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.
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.
If you are a Female patient, please indicate that you are not pregnant by initialing below.