Diagnostic Imaging Associates

Consent to Intra-Articular
Injection of Contrast Material

First Name: Middle: Last:
Age:
Date: xx/xx/xxxx
Time:
Email Address:

I hereby authorize Dr. to inject the contrast material within my body for the procedure.

The procedure has been explained to me and I am aware of the potential risks, consequences or complications involved with this procedure and I have read (or have had read to me) the possible complications below:

POSSIBLE COMPLICATIONS OF INTRA-ARTICULAR
INJECTION OF CONTRAST MATERIAL

This list is just an enumeration of the possible reactions encountered during an intra-articular injection of contrast material.

MILD REACTIONS WHICH REQUIRE NO TREATMENT:
• Hives
• Pain
• Swelling

MODERATE REACTIONS WHICH REQUIRE SOME TREATMENT WITH MEDICATION:
• Uticaria
• Facial edema
• Bronchial spasms
• Laryngeal edema
• Transient drop in blood pressure
• Inflammation in the joint
• Infection in the joint

SEVERE REACTIONS WHICH NECESSITATE HOSPITALIZATION:
• Angina
• Chest pain
• Convulsions
• Paralysis

FATAL REACTIONS OCCUR MOST FREQUENTLY IN PATIENTS OVER 50 YEARS OF AGE WITH PRE-EXISTING CARDIOVASCULAR OR RESPIRATORY DISEASES
Risk of infection in the joint Nationwide is: 1/25,000

If you are aware of any allergies, please tell the technologist no matter what it might be.

I certify that no guarantee or assurance has been made to me covering the results of this procedure.

I have read (or have had it read to me) this consent form and, by clicking on the consent box, confirm to my complete understanding of its content.

Patient Initials