IV CONTRAST CONSENT FORM

Your doctor has scheduled an examination that requires an IV injection of a contrast agent in your bloodstream. The contrast agent (also termed contrast media, or contrast material) shows up on your scan.


The contrast media is given through a small needle placed into a vein, usually on the inside of your elbow, or on the back of your hand. Normally, contrast media is considered quite safe; however, any injection carries a slight risk of harm, including injury to a nerve, an artery, vein, or a reaction to the material being injected. Occasionally, a patient will have a mild reaction to the contrast agent and develop sneezing or hives. Uncommonly, a serious reaction to contrast occurs. The physician and staff of the radiology department are trained to treat these reactions.


Very rarely, a death has occured related to contrast administration. The risk of such a severe consequence is similar to that from the administration of Penicillin.


Certain patients are at higher risk for experiencing a reaction to the contrast media:

  • Patients who have already had moderate or severe “allergic-like” reaction to the contrast material which requires treatment.
  • Patients with severe allergies or asthma.
  • Patients with severe or incapacitating heart disease.
  • Patients with severe kidney disease, particularly caused by diabetes.

If you believe you are in one of the above categories, please notify the medical imaging professional or physician.


If you have any questions, please ask the attending medical imaging professional or Radiologist to answer your questions.



I have read the above information and had my questions answered.

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