Nortonmri.com

Your doctor has requested that you have an arthrogram with contrast material (iodine based and MR contrast). Your physician feels that your scan may produce the best possible diagnosis using this method. For an arthrogram the iodine based contrast is injected directly into the joint.
Local anesthesis will be administered under the skin. A small needle will be placed into your joint using a sterile technique. Contrast and saline will be injected into your joint under fluoroscopic guidance. You will feel a pressure-like discomfort in your joint for 24-48 hours. There is low risk of bleeding or infection from this procedure.
Side effects from contrast, if any, usually do not require treatment. Many patients experience a warm feeling. Nausea and headache are among the most common symptoms. Statistically, less that 1 in 10 patients experience a headache while less than 1 in 20 patients experience nausea. As with any medication, allergic reactions are possible. Hives occur in less than 1 in 100 patients. There are less frequent complications, which may be more serious. Very rarely, a severe reaction may result in death (less than 1 in 40,000 injections). As with any contrast, potential injection site complications may occur.
Iodine based contrast and MR contrast may not be administered if you have any of the following conditions:
Some patients are at higher risk for side effects from contrast material. Please let us know if you have any of the
following:
Have you ever had a side effect from contrast media
Kidney disease or surgery or liver failure If yes, dialysis must be performed within 24 hours of injection If yes, please review breast feeding information sheet If breast feeding, milk must be expressed and discarded for at least 24 hours. Are you currently taking Glucophage (metformin), Glucovance (glyburide and metformin) or any other metformin containing medication? I have read and understand the information in the above form. My questions about contrast administration and its potential side effects have been answered to my satisfaction. I hereby authorize Alliance MRI Norton (Imaging Consultants, Inc.) to administer the contrast material and any potentially medically warranted emergency treatment.
Patient name: __________________________________________________________________________________ Signature (If the patient is under 18 a parent or guardian must sign) Witness: ______________________________________________________________________________ Procedure MD’s Name: ____________________________________________________________________________________ Expiration Date: _____________ Injection Site: _____________________ 246 East Main Street ♦ Norton, MA ♦ 02766 1. I hereby authorize Dr. ____________________ to treat the condition/conditions which appear indicated by the diagnostic studies already performed.
(explain the nature of the condition) 2. The procedure(s) necessary to treat my condition(s) has (have) been explained to me by Dr. ________________ and I understand the nature of the arthrography procedure.
3. The nature and pupose of the procedure, the benefits, possible alternative methods of treatment, the risks involved, the possible consequences and the possibility of complications have been explained to me to my complete understanding and satisfaction. 4. It has been explained to me that during the course of the procedure, unforeseen conditions may be revealed that necessitate an extension of the original procedure(s) or different procedure(s) than those set forth in paragraph 2. I, therefore, authorize the request of the above named physician to perform such surgical procedures as are necessary and desirable in the exercise of professional judgment.
5. I am aware that the practice of medicine is not an exact science; and there is the possibility, though not necessarily the probability, infection, or other complications even though the medical procedure(s) is carried out with a high degree of medical care and skill. I also acknowledge that no guarantees have been made to me concerning the results of any procedure.
6. I consent to the delivery of pain medication (analgesics) or sedating agents for comfort reasons, at the discretion of my physician. The risks, benefits, and alternatives to this have been explained to me by my physician.
Signature of patient, parent of authorized representative _________________________________________ __________________________________________________________ 246 East Main Street ♦ Norton, MA ♦ 02766

Source: http://nortonmri.com/pdf/ARTHROGRAPHY_CONTRAST_CONSENT.pdf