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Consent form (patient responsibility before study)

Cardiac and Vascular Center of North Texas Cardiovascular CT Studies

Consent Form
(Patient responsibility before study)
Name______________________________ Date____________________
Personal Physician_____________________ Age____________________
Weight___________ Height____________ Sex ___Male ___Female
Have you ever had:
___Yes ___No Any previous CT scan or X-ray tests using contrast or dye?
___Yes ___No Any reaction to contrast or dye?
If you did have a reaction, was it ___rash ___nausea ___hives ___trouble breathing
What else happened?__________________________________________________
Do you have:
___Yes ___No A history of allergies, hay fever or hives?
___Yes ___No An allergy to iodine or shellfish?
___Yes ___No Asthma or lung disease?
___Yes ___No Diabetes?
If yes, do you take: ___Glucophage/Metformin ___Avandamet
___ Glucovance ___Metaglip. When was your last dose?____________
Do you have:
___Yes ___No Drug allergies? Specify:_____________________
___Yes ___No Kidney disease?
___Yes ___No Only one kidney?
___Yes ___No Multiple myeloma?
___Yes ___No Dialysis?
___Yes ___No Could you be pregnant? ___Male patient
During this study, contrast media containing iodine will be administered through an intravenous line in
order to permit the acquisition of multiple X-ray images called a CAT scan. Prior to the acquisition of these
images, you will be administered a medication called a beta-blocker. This medication may be administered
orally and/or intravenously. Once an appropriate heart rate is obtained, you will be administered
intravenous contrast media. During the infusion of this contrast media, you may experience a warm feeling
throughout your body. Multiple X-rays will be obtained. Following the X-ray, you will be asked to drink
plenty of water and will be able to leave the Imaging Center shortly thereafter.
After the study is completed, the vascular portion of your study will be interpreted by a cardiologist,
cardiothoracic surgeon or vascular surgeon with the non-vascular portion being interpreted by a radiologist.
For the purposes of helping with advances in medicine, we ask that you allow your results to be used if
needed in research. If is used, your name and identifying data will be removed.
Cardiac and Vascular Center of North Texas PATIENT CONSENT AND DISCLOSURE You have the right, as a patient, to be informed about the recommended diagnostic procedure to be performed so that you may make a decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is simply an effort to make you better informed so that you may give or withhold your consent to the procedure. I (we) voluntarily request CSANT Cardiology and such associates; technical assistants, nurses and other health care providers as deemed necessary, to perform the procedure of a computerized tomography scan (CAT scan) of one or more portions of my body in order to visualize pertinent vasculature (blood vessels). I (we) understand that no warranty or guarantee has been made to me as to result or cure. Just as there may be risks in continuing my present condition without diagnosis or treatment, there are also risks and hazards related to the performance of diagnostic procedures planned for me. I (we) realize that common to diagnostic procedures is the potential for infection, blood clots, hemorrhage, allergic reaction and even death. I (we) also realize that the following risks and hazards may occur in connection with this particular procedure: injury to blood vessel, swelling, pain, tenderness or bleeding at the site of blood vessel puncture, aggravation of the condition that necessitated the procedure, allergic sensitivity to injected contrast media, low blood pressure and/or low heart rate, exacerbation of underlying lung condition. The medical staff who will perform my scan are trained to recognize and treat reactions that I might have, making this test as safe as possible. I (we) certify this form has been fully explained to me, I (we) have read it, or have had it read to me, that the blank spaces have been filled in, and I (we) understand its contents. I (we) have been given an opportunity to ask questions about my condition, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I (we) believe that I (we) have sufficient information to give this informed consent. ______________________________________ Date_____________________ Patient’s Signature ______________________________________ Date_____________________ Witness Signature Cardiac and Vascular Center of North Texas This form is designed to comply with the requirements promulgated by The Texas Medical Disclosure Panel Medical Treatment and Surgical Procedures established by the Texas Medical Disclosure Board. WAIVER FOR CARDIOVASCULAR CT STUDIES
Re: CT ANGIOGRAPHY – HEART AND/OR CORONARY ARTERIES As you are aware, Dr. ____________________ has recommended definitive evaluation and treatment related to your care. Your health insurance carrier may or may not authorize payment for the item(s) or service(s) described in this memo. Your carrier does not pay for all of your health care costs. Your carrier only pays for covered item(s) and service(s) pursuant to their coverage agreement. We have made every attempt to obtain a verbal approval or denial from your carrier. The fact that your carrier may not pay for a particular item(s) or service(s) does not mean that you should not receive it. There is a good reason your physician recommended this service. The purpose of this form is to apprise you of the potential that your carrier may not pay for the care outlined above and to allow you an opportunity to make an informed choice about whether or not you want to receive these item(s) or service(s), knowing that you might have to pay for them yourself. Please indicate below how you would like to proceed by checking one of the options. _______OPTION 1: Yes, I want to receive the item(s) or service(s) set forth above. I understand that my carrier may decide not to authorize payment for these item(s) or services(s). Please submit my claim to my insurance carrier. I understand that you may bill me for item(s) or service(s) and that I may have to pay the bill while my insurance carrier is making their decision. If my carrier does pay, I understand that you will refund to me any payments I made to you that are due to me. If my carrier denies payment, I agree to be personally, and fully responsible for payment. I further understand I can appeal my carrier’s decision, and that all documentation/records will be available from CSANT for such appeal _______OPTION 2: No, I have decided not to receive the item(s) or services(s) set forth above. I will not receive the item(s) or service(s) set forth above. Further, I understand the decision I have made in not receiving these item(s) or service(s) set forth above, and AGREE TO WAIVE ANY CLAIMS AGAINST DR__________________ arising from my not having such item(s) or service(s). ______________________________________________________ Date____________ Signature of Patient or person acting on patient’s behalf ______________________________________________________ Date___________ Witness


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