Download MRI Contrast Consent Form

2020 Court Street
Redding, CA 96001
Consent for MRI with Intravenous Contrast
Your physician has referred you to our facility for a magnetic resonance
examination. In certain cases, intravenous contrast solution using a Gadolinium
based agent (Gadopentetate Dimeglumine, Gadobutrol or Gadofosveset Trisodium)
is used to enhance the images and provide more information. This solution is
injected into a vein and highlights the structures of interest and has been approved
by the Food and Drug Administration as being safe and effective. If you have a
history of diminished renal function or kidney disease, please inform the
Technologist.
As with all medications, occasional side effects and complications are possible.
The injected contrast solution rarely causes headache, dizziness, nausea, vomiting,
feeling hot or altered sense of taste. Some laboratory blood tests in patients with
anemia or other blood diseases may be temporarily altered by this medication.
The Technologist and/or Radiologist who performs your MRI examination will
discuss this with you beforehand and will be glad to answer your questions. In
particular, you should let them know if you are pregnant, breast feeding, if you
have any anemia, or any other diseases that affect blood cells.
I have read and understand the above statement and I give my consent to have
MD Imaging perform this examination using intravenous contrast. I understand
that in spite of every skill and prudent effort made to avoid complications during
this procedure, there is no guarantee that a complication will not occur.
Signature of Patient/Guardian: _________________________________________
Print Patient/Guardian Name: __________________________________________
Date: _____________________________________________________________
Revised 12/6/2013