Mu02.1 e 304570 consenso informato english mdc

MU02.1 E 304570
UOC RADIOLOGIA dU
DECLARATION OF INFORMED CONSENT TO THE
USE OF IODINE BASED CONTRAST AGENT FOR
IMAGING EXAMS

TO BE COMPILED BY REFERRING PHYSICIAN

PATIENT_______________________________________________________________________________
AGE ______________________ WEIGHT (kg.) _________________SEX Male Female
Requested Exam:_______________________________________________________________________
Previously Diagnosed Conditions and Possible Risk Factors:
Previous adverse reactions to medication: □ YES □ NO □ NOT SURE if "YES", to which medication?________________________________________________________________ Has the patient received contrast agent in the past: □ YES □ NO Previous reactions to contrast agent: □ YES □ NO Is the patient taking medications (other than pre-medication for current exam): □ YES □ NO if "YES", specify: __________________________________________________________________________ Understanding the risks involved in the requested exam, I do however believe that it is in the best interest of the Patient’s health that the exam be performed. ________________________________________ seal and signature of the referring physician or specialist IN CASE OF POSITIVE HISTORY OF CONTRAST AGENT ALLERGIC REACTION (check one):
□ OUT-PATIENT (EXTERNAL): I declare that the Patient has received the required pre-medication of Prednisone
(DELTACORDENE) by oral administration of 25 mg 12 hours previous to exam and 25 mg 1 hour before exam.
□ IN-PATIENT: I declare that the Patient has received the required pre-medication:
a) if collaborative: same procedure as described above for OUT-PATIENT
b) if non-collaborative: with 100 mg of Hydrocortisone (FLEBOCORTID) I.V.: 50 mg 12 hours previous to exam and
The requested radiologic exam will not be performed if the patient has a past history remarkable
for allergic reactions, and has not been properly pre-medicated as prescribed above.
____________________________________________________ stamp and signature of referring physician or specialist MU02.1 E 304570
UOC RADIOLOGIA dU
DECLARATION OF INFORMED CONSENT TO THE
USE OF IODINE BASED CONTRAST AGENT FOR
IMAGING EXAMS

TO BE COMPILED BY THE PATIENT:

DECLARATION
I _____________________________________________________________________________ print full name here understanding that: • the use of I.V. administered, iodine based, contrast agent permits enhanced visualization of vessels and tissues during the radiologic exam, providing more information to better evaluate my clinical condition. • mild reactions to such contrast agent occur in about 5% of patients: consisting in itching, sneezing, and rash; less common mild reactions include mild respiratory difficulty and facial swelling; • more serious complications occur in about 0.02% (2 in 10,000) of Patients and include: serious allergic reactions, fall in blood pressure, cardio-circulatory collapse, serious respiratory difficulty; rarely (1 case in 60,000) these complications can lead to death; • the risk of an allergic reaction is increased in Patients suffering from diabetes, asthma, allergies to foods or medications, or who have had adverse reactions to iodine based contrast agents in the past. AUTHORIZE
with my signature to this document, the health service indicated above to perform intravenous administration of iodine based contrast agent. Verona, date: ________ ___________________________________________ patient's or guardian's (if Patient is a minor) signature

Source: http://www.radiologia-borgoroma-verona.it/files/consent_CA.pdf