Microsoft word - consent for ct iv contrast new.doc

PATIENT CONSENT FOR CT INTRAVENOUS CONTRAST
Patient: _____________________________________________________________________ Date of Exam: __________ Exam Ordered:________________________________________ IF YES WHAT ARE THEY: _____________________________________________________________________________________________ DID YOU EVER EXPERIENCE DIFFICULTY BREATHING OR SWELLING OF THE HANDS, FEET OR FACE ? DO YOU HAVE HAY FEVER OR SEASONAL ALLERGIES? IF YES WHAT ARE THEY: _____________________________________________________________________________________________ HAVE YOU EVER HAD A TEST/EXAM REQUIRING AN IV INJECTION OF CONTRAST IF YES DID YOU HAVE ANY REACTION TO THE CONTRAST MATERIAL USED? HAVE YOU EVER SUFFERED FROM OR DO YOU HAVE A HISTORY OF: IF YES, ARE YOU CURRENTLY ON ANY MEDICATION (PLEASE LIST)?____________________________________________________ If yes, are you taking any medications containing Metformin such as Glucophage,
Fortamet, Glumetza, Riomet, Glucovance, Metaglip, ActoPlus Met, Avandamet
OTHER DIABETIC MEDICATIONS YOU ARE TAKING ____________________________________________________________________ IF YES ARE YOU CURRENTLY ON ANY MEDICATION (PLEASE LIST)?_____________________________________________________ IF YES, ARE YOU CURRENTLY ON ANY MEDICATION (PLEASE LIST) _____________________________________________________ IF YES TO ANY OF THE ABOVE, PLEASE TELL THE TECHNOLOGIST IMMEDIATELY.
IF COMPLETING THIS FORM ON LINE, AND YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE CALL
HARTSDALE IMAGING IMMEDIATELY AT (914) 761-4030. WE WILL ADVISE YOU IF ANY ADDITIONAL
INFORMATION IS REQUIRED.

Your physician has referred you for a test requiring an IV injection of contrast. During the injection you may experience a warm, flushed sensation
and/or a bitter taste in your mouth. These sensations rapidly fade away and do not recur. Reactions such as nausea or even vomiting may occur but do
not require treatment. Minor allergic reactions such as hives, swelling, itching or skin rash are usually limited but may require medication. We use only
non-ionic contrast. This has a much lower incidence of side effects and is physiologically much safer. More serious allergic reactions are relatively rare
occurrences and medication is available to treat these conditions if they arise.
Contrast material may be toxic to the kidneys especially if you have chronic kidney disease. It is important that you drink large amounts of fluid in the
next 24 hours.
I, ___________________________________________ have read and understand the above and give my consent to have contrast injected. I
understand that in spite of every skill and prudent effort made to avoid complications during the examination, occasional complications do occur.
Do you require any further information?
THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ THE FOREGOING, RECEIVING A COPY THEREOF, AND IS THE PATIENT OR IS DULY AUTHORIZED BY THE PATIENT’S GENERAL AGENT TO GIVE CONSENT TO HAVE THE DESCRIBED PROCEDURE PERFORMED. DATE ________________________ PATIENT/PARENT/GUARDIAN ______________________________________________________ WITNESS SIGNATURE ______________________________________________________________

Source: http://www.hartsdaleimaging.com/pdf/CONSENT_FOR_CT_IV_CONTRAST_NEW.pdf