TO OBTAIN DIAGNOSTIC INFORMATION THIS EXAMINATION MAY REQUIRE AN INJECTION OF IODINATED CONTRAST MEDIA (ALSO KNOWN AS XRAY DYE), WHICH ENHANCES BODY ORGANS AND BLOOD VESSELS.

MOST PATIENTS EXPERIENCE A WARM SENSATION DURING THE INJECTION. AN ALLERGIC TYPE REACTION TOTHE INJECTION IS ALSO POSSIBLE. THE MOST COMMON REACTIONS INCLUDE NAUSEA, VOMITING, FLUSHING AND SNEEZING. OTHER REACTIONS MAY INLCUDE HIVES, CHILLS, SWELLING OF THE EYES AND LIPS,SWEATING, DIFFICULTY BREATHING, CARDIAC ARRHYTHMIAS AND RENAL FAILURE. RARE INSTANCES OF PROGRESSION TO DEATH DUE TO COMPLICATIONS HAVE BEEN REPORTED. HOWEVER, MEDICATIONS AND TRAINED PERSONNEL ARE ON HAND TO TREAT THESE CONDITIONS SHOULD ANY OCCUR. YOUR PHYSICIAN IS AWARE OF THESE POSSIBILE COMPLICATIONS BUT HAS DETERMINED THAT THE DIAGNOSTIC INFORMATION THAT THE EXAM PROVIDES FAR OUTWEIGHS THE MINIMAL RISK OF THE PROCEDURE.

I     CERTIFY THAT I HAVE READ AND UNDERSTOOD THE ABOVE PRESENTED INFORMATION AND THAT ALL MY QUESTIONS REGARDING THIS EXAMINATION HAVE BEEN ANSWERED TO MY SATISFACTION. I HEREBY AUTHORIZE DR. AJAY GOYAL OR A QUALIFIED PHYSICIAN OR TECHNOLOGIST TO PERFORM THE EXAMINATION AND ADMINISTER AN INJECTION OF CONTRAST MEDIA. IF ANY COMPLICATIONS SHOULD OCCUR I HEREBY CONSENT TO ANY ADDITIONAL TREATMENT NECESSARY.