Medical Imaging Contrast Exclusion Waiver Form
Complete this form to document the patient and imaging details, review contrast exclusion status, and acknowledge the waiver related to the exam.
Patient and Exam Details
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Imaging Date
*
-
Month
-
Day
Year
Date
Imaging Department or Location
Type of Imaging Exam Scheduled
*
Please Select
CT
MRI
Ultrasound
X-ray
Nuclear Medicine
Other
Contrast Exclusion Review
Is contrast excluded for this exam?
*
Yes, exclude contrast
No, use contrast
Pending review
Reason for exclusion
*
Relevant contrast history or reaction indicators
Prior allergic-type reaction
Shortness of breath after contrast
Hives or rash after contrast
Swelling after contrast
Prior severe reaction
Kidney function concerns
Other
Acknowledgment and Signature
Acknowledgment
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: