Download - Optim Imaging

247 SOUTH MAIN STREET, REIDSVILLE, GA, 30453
Department of Radiology and Imaging Services
Informed Consent for:
WITH
Have you had a CT of any type within the last 3 days?
IV
Yes
No
Have you had any type of Oral or IV Contrast within the last 3 days?
Have you had any type of X-Ray within the last 3 days?
ORAL
Yes
Yes
No
No
You have been scheduled for an exam that requires you to consume (drink) Barium Sulfate. The amount you must drink
depends on the type of exam your Physician has ordered, and other factors. An average is:
____Computed Tomography: otherwise known as a CAT Scan. = (2 bottles or 900ml)
Do not sign this form until you have read it and all questions have been satisfactorily answered for you.
Patient Name:
Date:
Date of Birth:
Age:
Hospital Number:
SS#:
BUN:
Creatin:
Dear Patient:
Please read the following form and answer all that applies to you. Please be sure to ask any and all questions that you
have concerns about prior to signing this form.
Are you pregnant or is there a possibility that you could be pregnant?
YES
NO
Please check any of the following that you currently have or have a history of:
Heart Problems
Kidney Disease
over Age 65
____ Latex/Rubber Products
History of Cancer
High Blood Pressure
Chemotherapy
Diabetes
Asthma
Sickle Cell Anemia
Currently Pregnant
Bronchial Asthma
___ Hay Fever
_
Allergic to:
_____________
___ Intestinal Perforation
___ Toxic Megacolon
___ Colonic Bx / Polypectomy(within 7 days)
___ Tape/Band-Aid Products ___ Advanced Cardiac Disease
Are you taking any of the following medication for Diabetes?
Glucaphage,
Glucovance
and/or Metformin
Yes
No
Other
Hold Glucphoage and medications containing Glucophage for 48 hour after the CAT scan only if IV contrast was
given. Medications containing Glucophage are, but are not limited to: Glucophage (Metformin)
Glucophage XR
Avandamet (rosiglitazone maleate/metformin Hcl)
Actoplusmet (actos plus metformin)
Metaglip (glipizide/metformin Hcl)
Fortamet
Glummetza
Actomet (actos/metformin)
Riomet (metformin)
Janum
Glucovance (glyburide/metformin Hcl)
Have you ever had a CT or Heart Cath before?
(Y)
(N)
Are you allergic to Iodine (Fish / Shrimp)?
(Y)
(N)
Do You Have any Known “FOOD” or “MEDICATION” Allergies
Name all known allergens: ____________________
______ YES _______ NO
_____________________
____
________________________________________________________________ __________
___________________________________________________________________________
If yes, give a brief description of what occurred?
You have been scheduled for the following exam that is marked. Please read carefully and make sure you
fully understand the contents of this consent form before signing or undergoing the exam.
( ) Intravenous Pyelogram, otherwise called IVP, is an examination of your kidneys to determine whether
or not you have a blockage of the tube which allows urine to drain your bladder. This exam will help determine
any blockage such as kidney stones or other abnormalities of the kidneys.
( ) Computed Tomography, otherwise known as CAT SCAN, requires the injections of x-ray dye to allow
the doctor to see the different organs in your body. This exam is done by taking several different pictures
through different parts of the body with a special machine that allows the doctor to see directly into the organs
such as the brain, liver, kidneys or other areas of the body.
( ) Venogram requires the placement of a small needle in the top of your foot and the doctor injecting x-ray
dye to fill the blood vessels in your legs to see if there is a blood clot causing swelling and/or pain in your leg.
(
)
Arteriogram or special procedure study as described below:
I have read and understand the type of test that I will be having and my questions have been answered to
my satisfaction.
Patient Signature:
Witness:
You have been scheduled for an examination that requires the injection of a contrast material into your
blood stream to better visualize the organs in question and to assist the radiologist with your x-ray or CAT
Scan interpretation.
The contrast material is given through a small needle placed into a vein. This vein is usually located on the
inside of your elbow or on the back of your hand. Normally, contrast material is considered quite safe.
However, any injection carries a slight risk of harm including injury to a nerve, artery, or vein; infection
or mild reaction to the contrast agent possibly with sneezing or hives. Uncommonly (one case in a
thousand) a serious reaction to the contrast occurs. The physicians and staff of the Radiology Department
are trained to treat these reactions. Very rarely, more serious complications have occurred related to contrast
administration. The risk of such a severe consequence is similar to that from the administration of a medication
that some people are allergic to or a bee sting type reaction. Once again, if this type of reaction were to occur,
the physician and staff of the Radiology Department are trained and have the medications available to treat such
reactions.
As a result of this procedure being preformed, there may be material risks of an infection, allergic reaction,
or disfiguring scar. Loss of function of any limb or organ, paralysis, paraplegia or quadriplegia, brain
damage, cardiac arrest or death. In addition to these material risks, there are other possible risks
involved in this procedure including, but not limited to, allergic rash, swelling of the lips or eyelids, and
difficulty breathing.
The likelihood of success of the above procedure is: (
) Good
(
) Fair
(
) Poor
Practical alternatives to this procedure could possibly include nuclear medicine, computed tomography,
ultrasonography, magnetic resonance imaging or diagnostic radiology.
It is our judgment that the performance or lack of performance of this diagnostic procedure will not necessarily
influence the patient’s prognosis other than to possibly withhold diagnostic information from the referring
physician.
I understand that the physician, medical personnel and other assistants will rely on statements about the patient,
the patient’s medical history, and other information in determining whether to perform the procedure or the
course of treatment for the patient’s condition and in recommending the procedure (which has been explained).
I understand that the practice of medicine is not an exact science and that no guarantees or assurances have been
made to me concerning the results of this procedure.
By signing this form, I acknowledge that:
 I have read or had this form read and/or explained to me, and I fully understand its contents.
 I have been given ample opportunity to ask questions; any questions were answered satisfactorily.
 All blanks or statements requiring completion were filled in; all statements I do not approve of were
stricken before I signed this form.
 I have received additional information including, but not limited to, the materials listed below relating to
the procedures described herein.
I voluntarily consent to Dr.
or any other physician designated or selected by him or her
and all medical personnel under the direct supervision and control of such physician and all other personnel
who may otherwise be involved in performing such procedures to perform the procedures described or
otherwise referred to herein.
Person giving consent:
Relationship to patient, if not the patient:
Witness:
Patient is unable to sign because:
Oral Contrast Record (Barium or Gastrografin)
Lot Number: _______________________________
Expiration Date: ______________________
Amount Given: _____________________________
Name Given: _________________________
Strength Given: ____________________________
Type of Exam: ________________________
Weight or grams: __________
247 SOUTH MAIN STREET, REIDSVILLE, GA, 30453
Department of Radiology and Imaging Services
CONTRAST INJECTION / IV SITE RECORD
Patient’s Name:
Circle One:
IP
OP
ER
Gender:
Male
Female
Hospital Number:
Date of Birth:
Diagnosis:
Type of Exam:
IV Started By:
Type of Needle Used:
Location of IV Site:
IV Removed By:
Date IV Started:
Date IV Removed:
Number of Sticks:
Amt. of Contrast Administered (mL):
Type of Contrast:
Strength of Contrast:
Lot Number:
Expiration Date:
Technologist Name, performing Contrast Injection:
Please write a brief description of the patient’s skin condition, after the removal of the IV, or if any
complication during injection or flushing of the site:
The purpose of this form is to document that an IV was started, the initials of the technologists who started the IV, and the location of
the IV. This for also will indicate that the IV was removed and the initials of the technologist who removed it. A brief description of
the patients skin should be documented, after the removal of the IV and if any complication during the procedure. This document is
not designed for and will not serve as a consent form. This is only a documentation form for starting an IV, the location of the IV and
the removal of the IV. This form will be placed with the patient’s medical records or X-ray jacket.
If the exam was ordered with contrast but was done without contrast please state the reason why.
If patient refused contrast please state why.
Patient Signature:
Was Doctor notified?
Witness: