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Mammography History and Pregnancy Form

N/A if not applicable
N/A if not applicable

I have been fully informed of the risks involved in radiation and assume the responsibility for any consequences from the procedure(s) I am about to have. I understand that I will not hold Imaging Specialists of the Medical University of South Carolina and its employees responsible for any potential harm to myself or my unborn child.

The radiation used in Mammography may be harmful to an unborn child. To prevent accidental irradiation, we require the following information of female patients of child bearing ages in accordance with national standards.