SoFHA
Patient Forms

CT Contrast Registry


Description:

The SoFHA Imaging Center CT contrast registry form.


Code:

19.005

Issued:

01/01/2022

Revision:

1

Revised:

N/A

CT Lung Screening





Do any of the following conditions apply to you?







Female Only






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

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