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Get Pregnancy Test Refusal Form

By signing this form you are acknowledging that you have been warned of potential risk to an before being scanned. Although you are encouraged to take the offered pregnancy test it is your right to refuse. PREGNANCY TEST RELEASE FORM INFORMED CONSENT CONCERNING POTENTIAL PREGANCY for MRI STUDY STUDY NAME PI This release is to inform you that Magnetic Resonance Imaging MRI may pose a hazard to an unborn child/fetus although there are no reports of injury to children who underwent MR imaging before birth. You may also decide to withdraw from this study if you so choose rather than take the pregnancy test. This release documents that you have been offered a pregnancy test before participating in this study and have chosen to decline. Signature of Person giving consent // Date Printed Name First Middle Last Signature of Witness to Person giving consent 1 of 1 06/06/11. You may also decide to withdraw from this study if you so choose rather than take the pregnancy test. This release documents that you have been offered a pregnancy test before participating in this study and have chosen to decline. This release documents that you have been offered a pregnancy test before participating in this study and have chosen to decline. Signature of Person giving consent // Date Printed Name First Middle Last Signature of Witness to Person giving consent 1 of 1 06/06/11. You may also decide to withdraw from this study if you so choose rather than take the pregnancy test. This release documents that you have been offered a pregnancy test before participating in this study and have chosen to decline. Signature of Person giving consent // Date Printed Name First Middle Last Signature of Witness to Person giving consent 1 of 1 06/06/11.

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Keywords relevant to Pregnancy Test Refusal Form

  • participating
  • scanned
  • fetus
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