Tick for Film, Disc (conditions apply), General x-ray, Theater, Mobile, CT#, Ultrasound, Angiography #%, Intervention #%, Fluoroscopy, Mammography, MRI$. # IV contrast requires questionnaire/consent. % Angio/intervention requires procedure consent. $ MRO requires safety questionnaire. Telephone bookings are required for special procedures
Previous iaging (last 12 months) - ask Pt to bring old films
Tick of Yes/No for Pregnancy, Infection risk (with Details ___), Allergies (with Details ___), renal disease (with eGFR or (creatinine) for all contrast exams ___). INR/Platelets: For angio/intervention ___
Referring specialist name, Contact, Provider No
Requesting MO name, signature, pager/phone, date __/__/___
Radiographer coments, ticks for Correct Pt, Correct site, Correct procedure/examination. Radiographer signature. Date __/__/___
Ionizing radiation (x-rays) should be used with caution, particualrly in children and women of child bearing age. Most x-ray exams are equivalent to days-weeks background radiation. Most CT exams are equivalent to months-years background radiation
The questionnaire/consent for imaging/CT with IV contrast, includes a Pt information sheet. The form itself includes:
Affix Pt label
eGFR: ___ and/or creatinine ___
(This form must be completed, and accompany request for Imaging/CT with IV contrast, or exam cannot be booked)
Requesting medical officer to complete: I have discussed the nature and purpose of the proposed Imaging/CT + IV contrast (dye) with this Pt. Requesting MO, sign, contact No (page/phone)
Pt (or guardian) to complete: Your Dr has requested Imaging/CT with IV contrast (dye) examination. Please answer the following questions, with the columsn Answer (YES/NO), and Details ___. Questionnaire includes:
Do you have a Hx of asthma?
Do you have a Hx of kidney disease?
Do you have myeloma or other blood disorders?
Do you have thyroid disease?
Do you have diabetes?
Do you take any oral diabetes medication, especially Metformin (Diabex, Glucophage, Diaformin)?
Do you have any significant allergies?
Have you ever had an x-ray examination involving IV injection where Iodine-based contrast (dye) caused a reaction?
Is there any chance you could be pregnant (or breast-feeding)?
It is hospital policy that you will have to complete this consent form prior to the imaging/CT study (unless exceptional/emergency situation). If you have any reservations or are uncertain please do not sign the following form. I have read Imaging/CT + IV contrast (dye) Information sheet (over page). I understand the nature and purpose of the scan, and I have understood the above screning questions. I commit to the procedure, and understand it carries small risk (as outlined in the information sheet). I have had the opportunity to ask questions, and I may withdraw consent at anytime
Authentication, including Patient (or guardian) sign, Date