CT Scan With Contrast Informed Consent Form
Please complete this form to provide the information needed before your CT scan with contrast and to acknowledge your understanding of the procedure.
Patient and Procedure Details
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Doctor or Clinician Name
*
Scheduled CT Scan Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Body Area or Scan Type
*
Please Select
Chest
Abdomen
Pelvis
Head
Neck
Spine
Other
Contrast Safety Screening and Medical History
Have you had a prior reaction to contrast dye?
*
No
Yes
Not sure
Which of the following allergies or sensitivities do you have?
Contrast dye
Iodine
Shellfish
Other
Do you have a history of kidney problems?
*
No
Yes
Not sure
If applicable, are you currently pregnant?
No
Yes
Not applicable
Are you taking any medications the clinician should know about?
*
No
Yes
Additional medical notes or details about previous reactions
Consent Acknowledgment and Signature
Consent Declaration
*
I understand and agree to proceed with the CT scan with contrast and acknowledge there may be risks or side effects related to contrast use; I had the opportunity to ask questions and my questions were answered
I do not agree
Patient Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: