Microsoft word - consent - ct iv contrast informed consent - revised 2013-07-15.doc

Consent Form
FORM.POL.002
Effective Date: July 15, 2013
CT IV CONTRAST INFORMED CONSENT
This x-ray examination is performed by using a special computer which allows us to view internal organs that we are not able to visualize using standard x-ray. Some CT examinations require the injection of a contrast media into your bloodstream. The use of this solution helps us to visualize certain organs inside the body that are not normally seen well and provides the radiologist with information which is necessary in evaluating your exam. The contrast agent is given through a small needle placed into a vein, usually on the inside of your elbow or on the back of your hand. Contrast media is considered quite safe; however any injection carries a risk of harm including injury to a nerve, artery, or vein, infiltration/extravasation, infection, potential of renal injury; or reaction to the material being injected. Occasionally, a patient will have a mild reaction to the contrast material and develop sneezing and/or hives. Uncommonly, more serious reactions have been known to occur, including life-threatening reactions. These serious reactions are rare. Please answer the following questions so that we may evaluate if you are at high risk for adverse effect to the contrast material:
†YES †NO FEMALE ONLY - Are you Pregnant?
†YES †NO Do you or have you had a reaction to x-ray contrast?
†YES †NO Do you have a history of “kidney disease” including tumor and transplant?
†YES †NO Do you have allergies or asthma? ________________________________________
(Please List Allergies)
†YES †NO Do you have a history of diabetes treated with insulin or other medications for
diabetes that are prescribed by a licensed physician?
†YES †NO Do you have a history of myeloma?
†YES †NO Do you have a history of pheochromocytoma or thyroid disease?
†YES †NO Do you have a history of collagen vascular disease?
†YES †NO Do you have a history of prior renal surgery?
†YES †NO Have you had a renal injury or have a history of renal/kidney injury? †YES †NO Do you have CHF (Congestive Heart Failure) or Heart Disease? †YES †NO Are you on certain medications? Metformin (Glucophage, Glucovance Fortamet, Glumetza, Riomet, Metaglip, Avandamet, Acto Plus Met) or Metformin-containing drug combinations. Long term use of non-steroidal anti-inflammatory drugs. Regular use of nephrotoxic antibiotics, such as aminoglycosides. Your doctor has ordered this CT exam to secure more information which will aid in the diagnosis of your condition. If you have additional questions regarding your exam, please feel free to discuss them with the Technologist or Radiologist prior to your scan. Your signature on this form indicates that you have: (1) Read and understood the information provided
in this form; (2) Authorize and consent to the performance of this procedure; (3) Have been informed
about this procedure; and (4) Had a chance to ask questions. 
 
Patient Printed Name: ________________________________________
Patient Signature: ___________________________________________ Date: ______________________ Parent or Guardian: __________________________________________ Date: ______________________ (If patient is a minor or has a legal guardian) Witness: ___________________________________________________ Date: ______________________ (Technologist or Radiologist Signature)

Source: http://valleyradiologyimaging.com/wp-content/uploads/2013/08/CT-IV-Contrast-Informed-Consent.pdf