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Consent for Evaluation using GE Dexa Scan

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.

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
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.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
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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