Radiology imaging associates

Radiology Imaging Associates
Patient Name: _____________________________________ Date: ______________________ Patient #: _________________________________________ Time: _______________am / pm Your doctor has requested an examination that requires the injection of contrast media in a vein in your arm. This will enable us to image specific internal structures of the body. The contrast may cause you to feel sensations such as a “metallic” taste in the mouth, coolness in arm, a general warmth, or nausea. These sensations are normal and will pass within a couple of minutes, or you may not feel them at all. A few patients experience allergic type reactions to the contrast, usually in the form of hives or itching. In rare cases, death has resulted. Since fatal reactions are so rare, it is difficult to quote accurate numbers, but it has been estimated to occur in less than 1 in 100,000 examinations. Your doctor is professionally knowledgeable of the procedure and the risks, and is recommending that you have the examination. Serious reactions to the contrast media are not common. Our doctors will be willing to answer any questions concerning the procedure. Consent:

I, _______________________________________________, hereby consent to the following procedure(s), _______________________________________________________________, to be performed by Radiology Imaging Associates and such assistants as may be selected. I understand that during the course of the procedure, unforeseen conditions may be revealed that necessitate an extension of the original procedure, or different procedures, than those set forth above. I therefore authorize the above named physician and his/her assistants to perform such diagnostic and therapeutic procedures as are deemed necessary in the exercise of professional judgment. I acknowledge that no warranty or guarantee has been made to me as to the results of the procedure(s). The nature of the procedure(s) listed above, the risks involved, and the alternative procedures available, if any, have been explained to me. I have been given the opportunity to ask any questions that I have regarding the procedure(s), and my questions have been answered satisfactorily. ____________________________________________________________________ ________________________________________ ______________________________________________ ________________________________________ Technologist:

 Is the patient using Glucophage/Glucovance (Metformin)? Yes / No (circle one)
 If yes, was the patient informed of need to discontinue Glucophage/Glucovance (Metformin) for at least 24
hours after the exam, and to contact their physician to ensure normal renal function prior to restarting
Glucophage/Glucovance? Yes / No (circle one)
Patient Signature: ______________________________ Date: ____________________________________ Technologist: _________________________________ Radiologist: _______________________________
Radiology Imaging Associates
Patient Name: _____________________________________________ Age/Sex: _____________ Patient #: _________________________________________________Date: ________________ Ref. Dr.: ____________________________________________ Phone: _____________________ Ref. Dx. per Rx.: ___________________________________________________________________________
____________________________________________________________________________________________ Patient Hx: _________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Other related exams: __________________________________________________________________________

Allergies (incl. insects): _______________________________________________________________________
Any chance of pregnancy No_____ Yes_____ Currently Breastfeeding No_____ Yes_____ *BUN / Creatinine levels if indicated: BUN____________________ / Creatinine: _____________________

Previous Contrast Injection: No_____ Yes______ Ionic or Non-Ionic? (circle one)
Adverse Reaction: No_____ Yes______ Notes: ___________________________________________ ___________________________________________________________________________________________ Previous surgeries: ___________________________________________________________________________ History of Cancer: ____________________________________________________________________________ Radiation Therapy (Duration): ________________________ Date of last Rx: _____________________________ Chemotherapy: ________________________________ Date of last Rx: ______________________________ Contrast: ____________________________________________ Amount: ___________________________cc
● Contraindication for use of ionic contrast? Yes / No ● Patient pretreated with steroids? Yes / No
Criteria for use of Non-ionic: _________________________________________________________________
Injection Site: Right / Left: Antecubital, Forearm, Hand, Wrist, Other: ____________________________ Method: Power Injector, Butterfly, Angiocath, Other: _____________________________________ _____
Sharps: 18G, 19G, 20G, 21G, 22G, 23G, Other: _____________________________________
Notes: _____________________________________________________________________________________
___________________________________________________________________________________________

Source: http://www.riassociates.com/files/contrast-questionair-reconsent.pdf