Consent to Intrathecal Injection of Contrast Material: Myelogram

First Name: Middle: Last:
Date: xx/xx/xxxx
Time:
Email Address:

I hereby authorize Dr. to inject the contrast material within my body for the procedure.

The procedure has been explained to me and I am aware of the potential risks, consequences of complications involved with this procedure and I have read (or have had read to me) the possible complications below.

I certify that no guarantee or assurance has been made to me covering the results of this procedure.

Premyelogram Instructions and Possible Risks and Reactions to Intrathecal Injection of Contrast Material

The test consists of a lumbar puncture followed by injection of contrast material within the spinal canal. The dye will show the nerves inside the spinal canal. After the dye is inserted, a few X-rays will be taken. The test lasts about 45 minutes.

After the test, you will remain in the recovery area for 1 hour. You will stay in a sitting position and will be checked regularly by our technologists. A post-myelogram CAT scan might also be done.

Please check YES or NO to each of the following questions:

Are you allergic to Iodine or X-ray dye? yes no
Do you have a history of EPILEPSY? yes no
Do you have a history of ALCHOLOISM? yes no
Have you had treatment with ANTIDEPRESSORS? yes no
Are you currently taking any ANTICOAGULANTS (blood thinners) or ASPRIN? yes no

MILD REACTIONS WHICH REQUIRE NO TREATMENT:
• Headaches
• Vomiting
• Nausea
• Increased back or leg pain

OTHER LESS LIKELY COMPLICATIONS:
• Infection
• Inflammation of the nerves due to local reaction of the dye
• Paralysis

When you leave the office, you will be given some medication for possible headaches, nausea, vomiting, or pain, and a separate sheet of instructions will be given to you.

I have read (or have had it read to me) this consent form and, by clicking on the consent box, confirm to my complete understanding of its content.

Patient Initials