The above imaging studies utilize radiation which can cause a broad range of complications to an unborn fetus, especially in the first trimester of pregnancy. It is the policy of Columbia Presbyterian Eastside Radiology (CPER) that imaging services not be routinely performed on women of child bearing age who cannot confirm that they are not pregnant.

I understand the above statement and I release CPER from any action or responsibility that may occur if I am pregnant, during my term of pregnancy or thereafter. I have been made aware that CPER does not routinely image patients who are do not confirm that they are not pregnant.

I am requesting that CPER perform the requested study(s). I have discussed my status (potential for pregnancy), with my referring physician and I conclude that the study is important enough to overlook any potential negative outcomes to a pregnancy, and absolve CPER from any legal and moral responsibility related to those potential outcomes.

Signature:	Date:
CPER Representative:	Date:

Rev 5/2/04