I hereby authorize the Supervising Radiologist and/or qualified Technologist to administer an injection of contrast medium for the purpose of enhancing body organs and vascular structures for a more complete diagnostic study.
I have been made aware that it is possible to experience an allergic-type reaction to the injection. The most common reactions include nausea, vomiting, flushing or a generalized feeling of warmth. Other reactions include hives, chills, fever, sweating, headache, dizziness, weakness, severe itching, sneezing etc. I understand that an adverse reaction is usually mild and transient, although life threatening reactions have occasionally been reported. For this reason, I understand that well trained personnel are available to treat me in the event of a serious reaction.
Notify the Technologist and/or Radiologist before signing, if you are taking Glucophage for Diabetes, or if you have any of the following conditions : sickle cell disease, multiple myeloma or pheochromocytoms.
I authorize the above to administer any additional medications or treatment deemed necessary to aid in the relief of any reaction.
I have read and understand the above and agree to the injection of contrast medium.