The checklist and consent must be completed BEFORE ...



The checklist and consent must be completed BEFORE scheduling the MRI/MRA.

|Date Ordered: | |Referring Physician: | |

|Medical Diagnosis/Symptoms: |

|Type of MRI/MRA (Check one): ( With Gadolinium |Patient Weight *:__________________________________ lbs |

|( Without Gadolinium |*Contact MRI for patients weighing greater than 350 lbs. |

MRI/MRA has been scheduled for:

PATIENT INTERVIEW

|Patient history criteria: |Yes |No |N/A |Occurrence Date |

|Pacemaker, heart valve, internal pumps, vascular filters, stents, shunts? | | | | |

|Implants in the eye, ear or any other body cavity? | | | | |

|Metallic surgical clips or metal parts (i.e., aneurysm clip, metal plates, pins, shrapnel, bullets, | | | | |

|IUD in the body)? | | | | |

|An eye injury involving metals? | | | | |

|Worked around cutting or grinding metal? | | | | |

|Hemodialysis on a scheduled basis? | | | |Next scheduled date is: |

|Pregnant? | | | | |

|Breastfeeding? | | | | |

|Claustrophobic? | | | | |

|IV line? | | | | |

|Cardiac monitor? | | | | |

|Ventilator? If on a ventilator contact Respiratory Therapy for assistance with transport. | | | | |

|Require oxygen during the exam? | | | | |

|Speak and understand English? | | | | |

|Hypertension? | | | | |

|Diabetes? | | | | |

|Renal Failure? | | | | |

|Liver Disease? | | | | |

|Serum creatinine outside range of 0.8-1.5 mg%** (within 7 days) | | | | |

Previous surgery? ( No ( Yes/list:________________________________________________________________________

|Signature of Interviewer: | |Date | |

|MRI/MRA CHECKLIST / CONSENT |Patient Label |

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|MRI Associates of Cheverly | |

| | |

| | |

|3-848 (12/03) | |

|Patient Name: | |Date: | |Time: | |

|Procedure | |

Technologist/RN/Physician Obtaining Consent: ________________________ Date:______________ Time:_____________

To enhance information on your MRI/MRA procedure, it may be necessary to administer an intravenous MRI Contrast agent. This material improves contrast to distinguish between normal and abnormal tissues within the body. It is a non-iodine agent and has been shown to be very safe with minimal to no reactions. Headaches, nausea and/or vomiting, a warm sensation and hives have been reported to occur occasionally. Serious reactions (seizures, respiratory distress and anaphylactic shock) have been reported to occur at a rate of approximately 1 per 150,000 injections. The injection will occur halfway through the exam.

There are no contraindications for the administration of MRI Contrast Media. Please inform the technologist about any prior contrast reactions, current pregnancy, breastfeeding, renal (kidney) disease, known drug allergies, asthma or diabetes. Patients with renal disease that require dialysis should have the injection within 24 hours of their next dialysis appointment. Pregnant and breastfeeding patients must have approval from the Radiologist for the injection.

If you have any questions, please ask the MRI technologist or radiologist.

CONSENT

I have read and understand the above information and have had my questions answered. I voluntarily consent to have the MRI procedure and injection of the contrast agent.

_________________________ Date:________ Time:______ ______________________ Date:_______ Time:_______

Witness Patient

|Complete the following section if consent is not obtained from the patient. |

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|Patient is unable to make an informed decision because patient is (Check appropriate box): |

|Minor ________years of age without decision-making capacity |

|Lacks decision-making capacity |

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|Other: ____________________________________________ |

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|Patient Representative Signature |

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|Relationship to Patient |

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|Witness Signature (1) |

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|Witness signature (2) |

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|Consent obtained (Check one): ( In person ( By Telephone (Requires two (2) witness signatures) |

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|Two physician signatures are required in an emergency for consent: |

|M.D. |

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|M.D. |

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|CONSENT FOR MRI/MRA CONTRAST (Page 1) |PATIENT LABEL |

|DIMENSIONS HEALTHCARE SYSTEM | |

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|5-111 (3/08) | |

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|Date: |____________________ |Time: |__________________ |

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