SoFHA
Patient Forms

CT Contrast Registry

Description:

The SoFHA Imaging Center CT contrast registry form.

Code:

19.005

Issued:

01/01/2022

Revision:

Revised:

N/A

CT Lung Screening

Legal NameFirst, MI, Last

Date of Birth

Reason for exam:

Have you ever had any x-rays or scans done this body part? Yes No

Do any of the following conditions apply to you?

Diabetes

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

History of Cancer

Yes No

Heart Failure

Yes No

Medication Allergies

Other Allergies

Have you had x-ray dye before?

Yes No

Did you have any complications or reactions?

Yes No

Previous SurgeriesOptional

Female Only

To the best of your knowledge, are you pregnant (or do you think you could be)?

Yes No Possibly Hysterectomy

What was the first day of your last complete menstrual period?

CT Intravenous Contrast (IV) Consent – Read only if you are receiving contrast for your exam.

Your doctor has requested a radiology examination that requires an intravenous (IV) contrast injection. The contrast material used is an iodine containing solution that circulates through the blood stream. The contrast is then collected by the kidneys, urinary tract and bladder. The contrast is urinated out of your body within a few hours.

Most patients experience no unusual effects from this injection. Occasionally, a patient may experience an arm sensation, nausea or vomiting. As with any procedure a few risks are involved. A small number of patients have a mild allergic-type reaction, such as swelling of the eyes and lips, sneezing or difficulty breathing. If you are highly allergic to foods and/ or medications or had a previous allergic reaction to CT contrast, please inform the technologist.

Serious or life threatening contrast reactions are extremely rare. Medications are on hand to treat these conditions, should they occur. Your doctor is aware of these possible complications but has determined that the additional diagnostic information provided by the contrast outweighs the minimal risks of this procedure.

I understand indications for and risks of the procedure known as a CT scan were discussed with me. The risks were noted to include, but are not limited to, various types of allergic reactions to the intravenous contrast (such as iodinated contrast etc.). Most of these reactions are minor, although they can be severe at times.

I have been advised that if further explanation is desired, I may ask additional questions to the staff to include any supervising radiologists.

Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Patient/Guardian Signature