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Parkwestradiology.com

Are you allergic to any of the following? Do you have allergies any other foods, products or medication? If you answer YES to any of the above allergies please contact Park West Radiology immediately at 212-874-6362 and provide further important details. Do you have any of the following conditions?Heart disease? If you answer YES to this question please contact Park West Radiology immediately at 212-874-6362 and provide further important details. Are you currently on Antibiotic treatment? If you answer YES to this question please contact Park West Radiology immediately at 212-874-6362 and provide further important details. List all medication you take for any of the above:Are you taking Glucophage, Metformin or Glucovance? If you answer YES to this question please contact Park West Radiology immediately at 212-874-6362 and provide further important details. List all previous surgeries with dates:Have you had a contrast dye injection before? Have you had any problems associated with this IV? If you answer YES to this question please contact Park West Radiology immediately at 212-874-6362 and provide further important details. Have you ever been diagnosed with cancer? If yes, Radiation Therapy and Dates:Chemotherapy and Dates:Are you currently on dialysis? If you answer YES to either of the above 2 questions please call Park West Radiology immediately at 212-874-6362 and provide further important details. APPLIES ONLY TO PATIENTS PRE MEDICATED FOR PROCEDURE Have you been premedicated for this exam? YES NO Have you finished your medication? YES NO I understand that withholding information or inaccurate information may adversely affect the interpretation of this study and I consent to this exam as ordered by my Physician.
*(Please sign at your appointment)
As part of my examination, I consent to have intravenous contrast material given to me. This intravenous contrast material is administered through a needle placed in the vein. The indications for this procedure havebeen explained to me. It has also been explained to me that the potential reactions to contrast, while rare,can include allergic reaction from mild to severe, swelling or infection of the injection site, bleeding, difficultybreathing, low blood pressure and kidney dysfunction.
There are two types of contrast available for use in your examination. The newer, non-ionic contrast agents,are less likely to produce reactions, than agents used in the past. Since the safety of our patients is our primary concern, we no longer use the older ionic contrast. New agents are more expensive and their useadds an additional $125.00 to the cost of the examination. Some insurance companies reimburse the additional cost. By signing below, I agree to pay the additional amount if my insurance company does notreimburse. I further consent to the administration of such drugs, infusions and other treatments necessary inthe judgement of the radiologist, should a reaction occur.

Source: http://parkwestradiology.com/form/pwrCTform.pdf

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