Consent Form

Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone Number/Contact Number *

(###)

###

####

Authorization *

By checking the box below, you consent to the echocardiogram procedure and understand the purpose, risks, and benefits. You also acknowledge that your medical information will be handled in compliance with the Health Insurance Portability and Accountability Act (HIPAA), ensuring confidentiality and privacy.

YES, I authorize ALORx medical imaging to perform my echocardiogram

Date *

MM

DD

YYYY