You’rescheduledforatestthatrequiresyoutoarriveearlytoensurethatthereisadequatetimeforscreeningandpreparationfortheexam.Anarrivaltimeisprintedabove;ifyoudonotseeanarrivaltimepleasearrive90minutespriortoyourappointmenttime.Ifyourappointmentisscheduledbefore8:40amyouMUSTpickupyouroralprepinadvance.Patientsthatpickuptheiroralcontrastinadvancecanarrive30minutespriortoyourappointmenttime,butnoearlierthan6:45AM.
Forthesafetyofall,childrenarenotallowedintheimagingrooms.Children17yearsandyoungermustremaininthewaitingroom.Childrenunder12mustbewithanotheradult(suchasafamilymemberorfriend)whileyouarehavingyourimagingprocedure.
NOSOLIDFOODFOR2HOURSPRIORTOYOURARRIVALTIME,CLEARLIQUIDISOK
OurhoursofoperationareMonday-Friday,6:45-5:30,andSaturday-Sunday7:30-3:30.Contactuswithanyquestionsat617-632-3215.
ABUN/CreatininemayberequiredpriortoaninjectionofCTcontrast.Thiswillbedeterminedafterareviewofyourmedicalrecords.IfyouhavehadarecentBUN/Creatininedoneatanoutsidehospitalwithin3weeksofyourexam,bringacopyoftheresultswithyou.ArriveatleastonehourpriortoyourCTScanappointmentifbloodworkisscheduledforthesameday.
CTscanning,sometimescalledCATscanning,isanoninvasivemedicaltestthathelpsphysiciansdiagnoseandtreatmedicalconditions.CTscanningcombinesspecialx-rayequipmentwithsophisticatedcomputerstoproducemultipleimagesorpicturesoftheinsideofthebody.CTscansofinternalorgans,bones,softtissueandbloodvesselsprovidegreaterclarityandrevealmoredetailsthanregularx-rayexams.
CTORALCONTRAST(TAKEHOME)HEALTHSCREENINGFORM
(onlyforstudiesthatincludethepelvis)
pleasecircleanswerbelow
1.DOYOUHAVEDIFFICULTYSWALLOWING,HAVEALLERGIESTOBARIUMSULFATEORHAVEAGIPERFORATION?
yes
no
Ifyesiscircled,thenrevieworderwithradiologistbeforeproceeding.
Ifnoiscircled,thenproceedtoquestion#2.
2.AREYOUALLERGICTOCONTRASTORIODINE?
yes
no
If,yes,iscircled,thendispensebariumonly.
If,no,iscircled,thenadministerOmnipaqueorbariumasperpatientpreference.
Ihavereceivedandunderstandtheinstructionspresentedtome.IhavebeengiventheopportunitytoaskquestionstoprepareformyCTscanwithoralcontrast,andhavenoquestionsatthistime.IunderstandthatifIhavequestionsatanytime,thatImaycontactDFCIRadiologyat617-632-3215.
Patientsignature:
Date:
Signatureofpersonscreeningthepatient:
Date:
TAKEHOMEOralcontrastoptions(onlyforstudiesthatincludethepelvis)
Contrasttype(circleappropriate):
OMNIPAQUE240%50ml
Takeasdirected.Refills:0
READI-CAT(BARIUM2.1%)450ml
Takeasdirected.Refills:0
InterchangeismandatedunlessthePractitionerwritesthewordsNosubstitutioninthisspace.
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