Local 3 Edificio C

CT SCAN Puerto Deportivo

CONSENT FORM Sotogrande
tel-600 44 33 00

Patient name Investigation

Your doctor has asked for a special x ray examination called a CT scan or computerized
tomography. During this test, a thin X ray beam is rotated around the area of the body the doctor
wants more information about.
The scan itself is painless, but you will have to remain completely still on the examination table while
the scan is being done.
In some cases, a special dye is needed to help the organs show up more clearly.
If this is necessary, your doctor will tell you.

RISKS

People are exposed to radiation from natural sources all the time. All x-rays involve a small extra dose of
radiation. The dose of radiation used for CT examinations is carefully controlled to ensure the smallest
possible amount is used that will still give a useful result. However, all radiation exposure is linked with a
slightly higher risk of developing cancer.
The size of any increased risk depends on the age of the patient and the total amount of radiation
received. The risk of any one scan is very small indeed, but increases if many scans are needed. The
doctor(s) asking for this test will have weighed any risk against the benefit to be gained from the extra
information the CT scan should provide.

I understand the procedure has the following specific risks and limitations:

There is a very small risk associated with radiation exposure. This cannot be avoided.
There may be risks associated with the use of x-ray dye
As a CT scan is usually avoided if a woman is pregnant, I should tell the staff if this may affect me
If I suffer from claustrophobia, I may find it difficult to remain still within the scanner and should warn the
staff beforehand

INDIVIDUAL RISKS

I understand the following are possible significant risks and complications specific to my personal
circumstances, that I have considered in deciding to have this scan:

…….….….….….….….….….….….….….….….….….….….….….….….….….….….….…...

DECLARATION BY PATIENT or PARENT

I acknowledge the radiologist has informed me about the procedure, other options and answered my
specific queries and concerns about this matter.
I acknowledge that I have discussed with the doctors any significant risks and complications specific to
my circumstances that I have considered in deciding to have this scan. I have received a copy of this
form to take home with me.

DECLARATION BY DOCTOR

I declare that I have explained the nature and consequences of the scan to be performed, and discussed
the risks that particularly concern the patient or the parent(s) /guardian(s).
I have given the patient and/or the parent(s)/ guardian(s) an opportunity to ask questions and I have
answered these.

Doctor’s signature Date

Signature of patient
/ parent/guardian
 Local 3 Edificio C
INTRAVENOUS CONTRAST Puerto Deportivo
ADMINISTRATION INFORMED Sotogrande
CONSENT
Tel: 600 44 33 00

As part of your examination we will need to inject you with a contrast material. This clear
colorless liquid is removed from your body by your kidneys and will not alter the
appearance of your urine. It will show up on your images to provide important diagnostic
information.
Soon after the injection you may experience a metallic taste and a warm sensation,
probably first in your face and head, and then in other parts of your body. You may feel
nausea, these feelings last only a short time.
Occasionally, minor reactions occur in the form of itching, sneezing, hives, swelling of the
eyes or wheezing. These symptoms may require treatment with medication we have at hand.

Rarely, a more serious reaction will occur, the health team members working with you today
are trained and equipped to assist you promptly if a problem occurs. Medical statistics
indicate that a fatality may occur in 1 (one) out of fifty thousand (50,000) injections. Your
personal physician is aware of the risk of complication and feels that the diagnostic
information to be obtained outweighs the small risk of the injection. We take every
precaution to obtain a good examination with maximum safety.
Please let us know if you have had a previous reaction to contrast media as part of a
kidney examination, angiogram, CT or other examination. We will be happy to answer
any questions you may have.
I______________________________________, have read and understood the above and
give consent to have a contrast injection. I understand that, despite every skill and prudent
effort made to avoid complications during the examination, there is no guarantee a
complication will not occur.

Signature of Patient/Parent/Guardian Date

Signature of Witness Date

 IV CONTRAST Local 3 Edificio C
QUESTIONNAIRE Puerto Deportivo
Sotogrande
Tel: 600 44 33 00

Please complete the following: Please circle

Have you ever been injected with intravenous contrast YES NO

Did you suffer any side effects or a reaction? YES NO

Do you have a history of:

Diabetes and are treated with metformin? YES NO

Allergies? YES NO

Thyroid disease? YES NO

Kidney disease? YES NO

Multiple myeloma? YES NO

Phaeochromocytoma? YES NO

Sickle Cell Disease? YES NO

For female patients of childbearing age YES NO

Are you breastfeeding? YES NO

Is there a chance that you may be pregnant? YES NO

Are you currently on any medications? YES NO

If so, please list:

………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………….
I have read the above information and am aware of the risks and benefits of being administered
intravenous contrast.
I have been provided with the opportunity to have any questions answered and I therefore give my
consent to injection of intravenous contrast.

PATIENT NAME SIGNATURE DATE

STAFF USE ONLY

Did the patient understand the information sheet? YES NO

Did the patient give verbal consent? YES NO

________________________________________________________________________________

AGENT CONTRAST LABEL TIME DOSE ml/SEC

________________________________________________________________________________
Scan performed by