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CT Scan File

CT

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MUHAMMAD ZAIN
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81 views

CT Scan File

CT

Uploaded by

MUHAMMAD ZAIN
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CHUGHTAI LAB (CL)

RIO/QF/L4/002 Patient Consent Form for CT Scan Examination Rev No: 1.0

Issue on: 20-12-2021 Review Date: -- Revision Date: 09-02-2023 Page 1 of 1

Patient Consent Form for CT Scan Examination


Patient’Name Age: Sex: LMP: Date:
Case No. Contact No.

Consultant Name Contact No.


Weight & Height _______ kg ________ Creatinine eGFR
BP Pulse SpO2 Tem

CT Examination required:
Presenting Complaint:

Past History:

Clinical Query:

Any Previous Radiological Examination / imaging:


X-Rays: CT:
Ultrasound: MRI:
Nuclear Medicine: Lab:
Any Contraindication / Precautions:

Asthma/allergy Pregnancy Previous Contrast Reaction

HTN Renal Failure Diabetes

Heart disease Known Coagulopathy Medication (Metformin)

Do you have any Surgical or Foreign Implant in your body Yes No

Any History of Seizure, Asthma, Allergic, Respiratory disease, HTN, DM Yes No

Total contrast given ________ ml Doctor/Technologist

Content:
The above test has been advised by Dr ___________________ I have explained all the details of procedure, its
Risks and benefits. I authorize CHUGHTAI HEALTHACRE to carry out the above procedure and any medication
Or hospitalization deemed necessary for my welfare. In case of emergency patient will be given first aid and
shifted to the nearest hospital. I also authorize CHUGHTAI LAB to use my study in educational research
considering ethical and identity issues.

Name Relation to patient

Contact # Signature

Approved by Head of Department Dr. Furqan Ahmad dated 09 February, 2023


Reference: SOP for CT Scan
CONTROLLED

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