Diagnostic Imaging Associates

Consent to Intravenous Injection
of Contrast Material

Diabetic? yes no
Glucophage? yes no

Brandywine
Omega Imaging
Pike Creek
Glasgow

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 RISKS AND REACTIONS TO INTRAVENOUS INJECTION OF IODINATED CONTRAST MATERIAL

This list is just an enumeration of the possible reactions encountered during injection of contrast material. The risk of having one of these reactions is very low, especially for the severe reactions.

MILD REACTIONS WHICH REQUIRE NO TREATMENT:
• Metallic taste in the mouth
• Flushing
• Nausea, vomiting
• Tingling
• Light-headedness
• Sneezing, coughing
• Hives

MODERATE REACTIONS WHICH REQUIRE SOME TREATMENT WITH MEDICATION:
• Itching
• Racial edema
• Bronchial spasms
• Laryngeal
• Transient drop in blood pressure
• Headaches
• Infection at the puncture site

SEVERE REACTIONS WHICH NECESSITATE HOSPITALIZATION:
• Prolonged drop in blood pressure
• Angina
• Chest pain
• Convulsions
• Coma
• Paralysis

FATAL REACTIONS OCCUR MOST FREQUENTLY IN PATIENTS OVER 50 YEARS OF AGE WITH PRE-EXISTING CARDIOVASCULAR OR RESPIRATORY DISEASES
The percentage of fatal reactions Nationwide for I.V. contrast is: 6/100,000 (very low probability and is like being fatally hit by a car in a big city)

If you are aware of any allergies, please tell the technologist no matter what it might be.
If you have had I.V. contrast X-ray studies, and had a reaction, please tell the technologist.

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