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Advanced Medical Imaging
Advanced Medical Imaging
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Advanced Medical Imaging
Advanced Medical Imaging
9555 Seminole Blvd, Suite 101, Seminole, FL 33772
(727) 398-5999  ·  Fax: (727) 231-0772
Date: ___________________

Contrast Media (IV Dye) Consent Form

Required only if your exam involves intravenous (IV) contrast material. Our technologist will advise you.

Required — Contrast Studies

This form is only required if contrast dye is ordered for your exam. If you are unsure whether your exam involves contrast, please ask our front desk staff or technologist.

1. Patient Information

2. About Contrast Media

What is IV Contrast?

IV contrast (also called contrast dye) is a substance injected into a vein to improve the visibility of blood vessels, organs, and certain abnormalities on imaging studies. For CT scans, iodine-based contrast is used. For MRI scans, gadolinium-based contrast is used.

Possible Risks and Side Effects

Most patients experience no side effects. Known risks include:

  • Mild reactions (most common): Nausea, warmth, flushing, mild hives, itching, metallic taste. Usually self-limiting.
  • Moderate reactions (uncommon): Vomiting, significant hives, mild bronchospasm. Treated with medication.
  • Severe reactions (rare, ~1 in 10,000): Severe allergic reaction (anaphylaxis), drop in blood pressure, severe bronchospasm, loss of consciousness. Emergency treatment available on-site.
  • Contrast-Induced Nephropathy (CIN): Temporary worsening of kidney function in patients with existing kidney disease. Rare at standard doses.
  • Gadolinium retention (MRI contrast): Trace amounts of gadolinium may deposit in tissues; clinical significance unknown for standard doses.
  • Extravasation: Rare leakage of contrast outside the vein — may cause swelling, pain, and rarely tissue injury.

Risk Factors That Must Be Reported

Your risk of a reaction may be increased if you have any of the following. Please disclose all that apply:

3. Risk Factor Screening

Do you have a history of allergic reaction to IV contrast or iodine dye?

Do you have asthma or other significant respiratory disease?

Do you have known kidney disease, single kidney, or are you on dialysis?

Are you diabetic and taking Metformin (Glucophage)?

Do you have a history of multiple myeloma or other plasma cell disorders?

Do you have sickle cell disease?

Do you have an allergy to shellfish (iodine-containing foods)?

Are you currently pregnant or could you be pregnant?

Are you breastfeeding?

Are you taking any blood thinners (warfarin, Eliquis, Xarelto, etc.)?

4. Recent Kidney Function (CT Contrast)

For CT exams with IV contrast, a recent serum creatinine or eGFR may be required, especially if you have diabetes, kidney disease, or are over 60.

5. Informed Consent & Signature

I have read or had explained to me the information about contrast media, including the purpose, possible benefits, risks, and alternatives. I have had the opportunity to ask questions and my questions have been answered to my satisfaction.

I voluntarily consent to the administration of intravenous contrast material as part of my imaging examination. I understand that no guarantee has been made about the results of this procedure.

I understand that if I experience any discomfort, difficulty breathing, swelling, rash, or other unusual symptoms during or after the procedure, I should notify staff immediately.
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