CT Contrast Consent Form

Patient details

First Name *

Last Name *

Mobile number *

Date of your booking

Which centre are you attending?

Consent

Your doctor has requested for an examination which may require an intravenous injection of an iodine-based contrast medium (x-ray dye). This allows for more detailed information in a relatively safe manner.

The injection is often associated with a warm feeling around throughout the face and body which lasts for 1 minute.

In rare cases (1 in 1,000 injections), a mild allergic reaction such as rash or sneezing may occur.

Even more rarely (1 in 180,000), a more severe reaction can occur. This can include asthma, shock, and circulatory disturbance. Severe life- threatening reactions up to and including death have occurred but are extremely rare.

Please sign the consent and complete the following questionnaire. There will be an opportunity to discuss this further with the clinical staff before commencing with your examination. Any further questions will be readily answered and you can change your consent preference before the scan.

I have read and understood the information above *

I GIVE consent to the administration of contrast media (x-ray dye injection)I DO NOT GIVE consent to the administration of contrast media (x-ray dye injection)

Please sign *

Clear

Questionnaire

1. Have you had a previous x-ray dye injection? *

No Yes

1.1 Did you have any allergic reaction to the injection? *

NoYes

Details (what occurred during the reaction)

2. Do you have Diabetes? *

NoYes

Details of diabetes severity and treatments

3. Do you have any heart, kidney or thyroid disease? *

NoYes

Details

4. Do you have Myasthenia Gravis or Sickle Cell Disease? *

NoYes

Details

5. Do you have asthma? *

NoYes

Details of asthma severity and treatment

6. Are you pregnant or breastfeeding? *

NoYes

Details

7. Are you a current or ex-smoker? *

NoCurrentEx-smoker

Current Smoker (cigarettes/day)

Current Smoker (number of years)

Ex-Smoker (number of years smoking)

Ex-smoker (number of years ceased)

8. Do you have any allergies? *

No Yes (please list)

Allergy (mention if there is a history of anaphylaxis)

9. Have you had any surgery? *

NoYes

Surgery details and body region

Date of surgery

10. Are you on any regular medications? *

NoYes

Medication name

Dose/strength (mg)

Frequency

OR please upload a copy of your current medications

Browse

11. Clinical history (please describe why your doctor has referred you for this scan. Include symptoms, body region affected, and any other relevant information) *

Renal Function Results Date:

Pathology Clinic

Creatinine

eGFR

Patient Height (cm) - Only for aortogram or cardiac patients

Patient Weight (kg) - only for aortogram or cardiac patients

Radiographer Notes: