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Get CA Antioch Medical Imaging Pregnancy Verification Form

Te of last menstrual period: ___________________   YES   NO  You’re pregnant or suspect you may be pregnant?   YES   NO  Are you breast‐feeding?    I have informed the technologist that I am NOT pregnant at this time.      Patient’s Signature        Date      I understand I will be receiving x‐rays and hereby release all radiologists, respective staff and  the facility thereof of any and all respons.

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