PLACE LABEL HERE

INFORMED CONSENT FOR GADOLINIUM

MAGNETIC RESONANCE IMAGING (MRI)

EXAMINATION

(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)

PATIENT NAME: ______DATE: ______TIME: ______

The diagnosis or clinical history requiring this procedure is:

The nature of the procedure is: Intravenous Injection of a Contrast Agent Specific for MRI Examination______

Gadolinium is an extremely safe contrast medium developed specifically for magnetic resonance imaging and has been approved by the FDA. There are no absolute contraindications to administration and reactions are very unusual. Approximately 1-2% of patients may complain of headaches, nausea, injection site coldness or taste perversion. All other adverse events occurred in less than 1% of the patients.

PLEASE INFORM THE TECHNOLOGIST IF YOU ARE:

  1. Pregnant or breast feeding
  2. Have anemia or any diseases that affect red blood cells
  3. Have asthma or other allergic respiratory disorders
  4. Have a history of renal or hepatic disease

The purpose of this procedure is: to better see body tissues in order to get the most information from the test being done.

THIS PROCEDURE INVOLVES THE MATERIAL RISK OF INFECTION, ALLERGIC REACTION, SEVERE LOSS OF BLOOD, LOSS OF FUNCTION OF ANY LIMB OR ORGAN, PARALYSIS, PARAPELGIA OR QUADRAPLEGIA, DISFIGURING SCAR, BRAIN DAMAGE, CARDIAC ARREST OR DEATH.

Please note that serious adverse reactions to these contrast agents are extremely rare. Over 5 million doses have been administered and severe anaphylactoid (allergic) reactions have been reported at an approximate frequency of only 1 in 400,000 patients.

The likelihood of success of this procedure is: good  fair  poor

The practical alternatives to this procedure are: COMPUTED TOMOGRAPHY (CT), RADIO NUCLIDE IMAGING STUDY, MYELOGRAM, ARTERIOGRAM.

It is our judgment that the performance or lack of performance of this diagnostic procedure will not necessarily influence the patient’s prognosis other than to possibly withhold diagnostic information from the referring physician.

I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient’s medical history, and other information in determining whether to perform the procedure or the course of treatment for the patient’s condition and recommending the procedure which has been explained.

I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.

*2-13020* FORM 2-13020 REV. 04/2018 Page 1 of 2

PLACE LABEL HERE

INFORMED CONSENT FOR GADOLINIUM

MAGNETIC RESONANCE IMAGING (MRI)

EXAMINATION

(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)

I understand that during the course of the procedure described above, it may be necessary or appropriate to perform additional procedures, which are unforeseen, or not known to be needed at the time this consent is given. I consent to and authorize the persons described herein to make the decisions concerning such procedures. I also consent to and authorize the performance of such additional procedures as they deem necessary or appropriate.

BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR EXPLAINED TO ME IN GENERAL TERMS, THAT I FULLY UNDERSTAND ITS CONTENTS, AND THAT I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY. ALL BLANKS OR STATEMENTS REQUIRING COMPLETION WERE FILLED IN AND ALL STATEMENTS I DO NOT APPROVE OF WERE STRICKEN BEFORE I SIGNED THIS FORM. I ALSO HAVE RECEIVED ADDITIONAL INFORMATION, INCLUDING BUT NOT LIMITED TO THE MATERIALS LISTED BELOW RELATING TO THE PROCEDURE DESCRIBED HEREIN.

Additional materials used, if any, during the informed consent process for this procedure include:

I have received information and instructions about the contrast medication used during my procedure. I understand and accept these instructions. My questions have been answered.

I hereby voluntarily request and consent for Dr. ______, as my physician, and any other physician(s), and such associates, assistants or other medical personnel involved in performing such procedure(s), to perform the procedure(s) described or referred to herein.

______

DateTimeSignature of Person Giving Consent

Relationship to patient if not the patient: ______

Patient unable to sign because: ______

Responsible Practitioner’s Statement:

I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed procedure, with the patient or the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask questions.

at the direction of

Signature of Person Obtaining ConsentName of Responsible Practitioner

Patient/person giving consent refused procedure:

______

DateTimePatient/Authorized Person Signature

______

Authorized Person / Relationship

FORM 2-13020 REV. 04/2018 Page 1 of 2