WHOLE BODY COMPOSITION DEXA SCAN CONSENT AND ACKNOWLEDGMENT

1. Nature and Scope of Service

I understand that this service consists solely of a Whole Body Composition DEXA scan and a standardized written interpretation guide.

I understand that this service:

• Does not include medical diagnosis, treatment, or individualized medical advice

• Is not a comprehensive medical evaluation

• Is elective and not medically required

The purpose of this scan is informational body composition assessment for general health, wellness, and fitness tracking.

2. Not a Formal Diagnostic or Official Medical Study

I understand that:

• This scan is provided for informational, fitness, and general health tracking purposes.

• This is not an official diagnostic medical study performed as part of a physician evaluation or hospital-based imaging service.

• The results are not automatically reviewed, signed, or certified by a physician unless I schedule and complete a separate medical consultation.

• This scan is not intended to serve as a formal medical report for disability determination, insurance claims, legal proceedings, or specialist referral unless I obtain a physician consultation.

The clinic may perform periodic internal quality assurance review at its discretion.

3. Radiation and Safety Acknowledgment

I understand that a DEXA scan uses a low dose of ionizing radiation. The radiation exposure is generally lower than that of a standard chest X-ray, but no medical procedure is entirely without risk.

I confirm that:

• I am not pregnant.

• I do not believe I may be pregnant.

• I will notify clinic staff immediately if there is any possibility of pregnancy.

I understand that if I am pregnant or may be pregnant, I should not undergo this scan.

4. Incidental Findings

I understand that this scan is not intended to diagnose medical conditions.

If unexpected or potentially concerning findings are identified, the clinic may recommend that I seek further medical evaluation. It is my responsibility to follow up with a physician if advised.

5. No Automatic Physician–Patient Relationship

I understand that undergoing this scan does not establish an ongoing physician–patient relationship.

A physician–patient relationship is established only if I separately enroll in a membership program or schedule and complete a medical consultation.

6. Educational Nature of Interpretation Guide

I understand that:

• The interpretation guide is standardized and template-based.

• It is not individually customized to my medical history unless I schedule a separate physician consultation.

• The information provided is educational in nature and does not constitute personalized medical advice.
  

I understand that I am responsible for seeking medical evaluation if I have concerns about my results.

I understand that abnormal or concerning findings may require further medical evaluation and that it is my responsibility to schedule a consultation if I wish to discuss my results with a physician.

Any decisions I make regarding exercise, diet, supplementation, or medical care based on this scan are my responsibility unless I receive individualized medical advice during a separate consultation.

7. Insurance and Payment Acknowledgment

I understand that this service:

• Is not billed to insurance

• Is not covered by insurance

• Is paid for directly by me
  

I agree to the stated pricing and payment terms at the time of booking.

8. Electronic Communication Consent

I consent to receiving my scan results and related communications electronically at the email address I provide.

I understand that electronic communication, including email, may not be fully secure, and I accept this risk.

I confirm that the email address I provide is accurate and that I am authorized to receive information at that address.

Results are typically delivered electronically within 5 business days.

9. Cancellation Policy

I understand and agree to the following cancellation policy:

• Rescheduling is free up until 24 hours before the appointment.
• There is a $20 fee to re-schedule within 24 hours of the appointment.
• Cancellations more than 24 hours before the appointment are eligible for a full refund.
• Cancellations within 1–24 hours are eligible for a 50% refund.
• Cancellations within 1 hour of appointment time and no-shows will not receive a refund
  

10. Limitation of Responsibility

I understand that this service is limited to performing the DEXA scan and providing standardized educational materials.

The clinic is not responsible for how I interpret or act upon this information unless I schedule and complete a separate medical consultation.

11. Final Acknowledgment

I certify that:

• I have read and understand the information above.
  
• I voluntarily agree to proceed with the Whole Body Composition DEXA scan under these terms.