Microsoft word - radiology consent for_ct scan with contrast_ivp_cy

Doctors Memorial Hospital - Radiology Department Consent for IV Iodine Administration
Name: _________________________________________________ Height: ____________ Weight: ______________ Current Medicines_________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Food/Drug Allergies ______________________________________________________________________________________________________ 2. Have you ever had an injection of intravenous contrast material (contains iodine)? If Yes, Did you have any reaction other than; sensation of heat, flushing, or single episode of nausea or vomiting? 3. Has a doctors ever diagnosed you with; If yes, specify ______________________________________________ If yes, specify ______________________________________________ 4. Do you take any of the following diabetic medications containing Metformin? (Glucophage,Glucuvance, Avandamet, Metaglip, Fortamet, Riomet, Actoplus) If yes, Has it been discontinued for 24 hours prior to the procedure? (Please consult physician before resumption) 5. Do you take beta blockers for your heart? Examples of beta blockers include; Sectral, Tenormin, Kerlone, Zebeta, Cartrol, Coreg,Brevibloc, Normodyne, Trandate, Lopressor, Toprol XL, Corgard, Levatol, Visken, Betachron E-R, Inderal, Inderal LA, Betapace, Blocadren 6. Have you had a recent oral cholecystogram? Your physician has scheduled you for a radiographic examination that requires the injection of a contrast agent in your blood stream. An x ray is a picture of what is inside you.
The contrast material (also known as x ray dye) stands out on the X ray film or CT scan image and helps the Radiologist inter pret the examination. The contrast material is given toyou through a small needle placed in a vein. Normally, a contrast material is safe. Any injection, however, carries a slight risk of harm, including an infection, or an injury to anerve, artery or vein.With a contrast injection, a patient will occasionally have a mild reaction to the contrast material and develop nausea, sneezing or hives. Uncommonly (1 casein 1000), a more serious reaction to the contrast material occurs. The staff is trained to treat such a reaction. Very rarely , (highest reported rate is 1 case in 10 000), death hasoccurred related to the contrast material’s administration.
For a complete explanation of the nature of the procedure, potential benefits, risks, side effects, problems in recuperation , the likelihood of achieving the service goal, reasonablealternatives to the service, relevant risks, benefits, side effects related to alternatives and the possible results of not r eceiving the service, please contact a Radiology staff member.
I have read and understand the above information. I attest that the information provided is correct and consent to receiving the contrast.
Signed ____________________________________________________ For Doctors Memorial Hospital Staff only
Examination_______________________________________________________________ Diagnosis_________________________________________________________________ Gastrografin/Gastroview ______ml + ______ ml water/juice Tonopaque (Ba 40% w/w) _________ 270ml bottles Signature ______________________________________ Drug Interaction identified per First Databank? Signature ______________________________________

Source: http://www.doctorsmemorial.org/pdfs/Radiology%20Consent%20for_CT%20Scan%20with%20contrast_IVP_Cystogram.pdf