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Get and Sign CONTRAST DYE SCREENING FORM Virginia 2008-2022

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Signature Please call 434 924-9400 and ask for the Radiology resident on call if you have any concerns. 243. 9198 Fax 434. 243. 0243 PATIENT NAME MR CONTRAST DYE SCREENING FORM ADDRESSOGRAPH Before beginning your study it is necessary that you answer the following questions COMMENTS / DESCRIBE Have you ever had contrast material dye for a kidney x-ray CT MRI or other imaging test/study YES NO If YES did you have any discomfort ill effects or allergic reaction If Yes Describe Do you have asthma...
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