CT with Contrast Patient Forms

I understand that:

• The practice of medicine is not an exact science and no guarantee can be made as to the results that might be obtained from this procedure.
• Complications can occur. By consenting to this exam, I hereby consent to the necessary medical or surgical actions of the physician and/or colleagues, medical/surgical; whomever they choose to consult with to take
  appropriate actions in regard to this procedure should any complications occur during my visit.
• MedRVA Imaging may include consent at satellite offices under common ownership.

Patient Financial Responsibility

I understand my financial responsibility and I guarantee payment for all charges not covered by my insurance, all applied deductibles and co-pays, within 30 days of receiving a statement.

Medicare Patients

I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to MedRVA Imaging.

I, the undersigned, authorize MedRVA Imaging to use and disclose my information for the purposes of treatment, payment, and healthcare operations. A photocopy of this consent shall be considered as valid as the original.

 I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Contrast Information

As requested by your physician, CT contrast may be necessary to aid the radiologist in evaluating your scan. The use of this solution helps to visualize certain organs inside the body that are not normally seen well and provides the radiologist with information that 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. The Food and Drug Administration has approved this agent and it is considered quite safe; however any injection carries a risk of harm including injury to a nerve, artery or vein, extravasation of the contrast under the skin, infection, potential or renal injury; or reaction to the contrast itself.

A small percentage of patients receiving CT contrast may develop a mild allergic reaction, the most common being hives. Same patients develop sneezing or itchy, watery eyes. Mild allergic reactions such as these are typically treated with antihistamine. Uncommonly, more serious reactions have been known to occur, including life-threatening reactions. These serious reactions are rare.