CT Imaging Patient Screening/Consent Form

Patient No:

Type a question

	Yes	No	n/a
01. Are you allergic to any medications?
02. Are you allergic to any foods or other substances?
03. Have you ever experienced a rash, hives or difficulty breathing, from IV contrast (dye) used for CT scans?
04. Have you had any studies with contrast (dye) in the last 48 hours?
05. Do you have asthma?
06. If yes, do you use a daily inhaler?
07. Do you have kidney failure?
08. Are you diabetic currently taking Metformin based medication?
09. For female patients, are you pregnant or could you be pregnant?

When is the last time you ate or drank?

CONSENT FOR CONTRAST MATERIAL INJECTION:

Your doctor has scheduled you for a CT examination that requires an injection of a contrast agent in your bloodstream. The contrast agent, also called contrast media, contrast material or X-ray dye assists the radiologist in interpreting your CT scan.

The contrast media is given through a small needle placed into a vein, usually on the inside of your elbow or on the back of your hand. Normally, contrast media is considered quite safe. However, an injection carries slight risk of harm including injury to the skin, a nerve, artery, or vein. An infection or reaction to the material being injected can also occur. Occasionally, a patient will have a mild reaction to the contrast agent or develop sneezing or hives. Uncommonly (one case in a thousand) a serious reaction to the contrast occurs. Our physicians and staff are trained to treat these reactions. Very rarely (1:100,000) death has occurred related to contrast administration. The risk of a severe consequence is similar to that of administration of penicillin.

Certain patients are at a higher risk for experiencing a reaction to the contrast agent. For this reason, we use a contrast agent called “low-osmolar” or
“non-ionic” contrast, which appears to have a lower incidence of reactions. However, these newer agents are not absolutely free of reactions, even
serious ones.

Patients who are at higher risk for adverse effects of contrast are patients:

Who have already had a moderate or severe “allergic-like” reaction to contrast material which required medical treatment or
hospital treatment.
With severe allergies or asthma currently receiving drug treatment
With severe kidney failure, particularly caused by diabetes

If you believe you are in one of the above categories, or have any questions, please notify or ask the radiographer or radiologist.

I have read the above information and had my questions or concerns answered.

Consent obtained by

Name

First NameLast Name

Date

Patient Signature

Name

First NameLast Name

Date