Get Ct Simulation Contrast Request & Iv Contrast Screening Form - Virginia

Filling out the CT Simulation Contrast Request & IV Contrast Screening Form is a crucial step in the scheduling of your CT simulation. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Begin by completing the contrast request section. Indicate the type of contrast required, choosing between oral and IV options. Specify the exact type of IV contrast needed, such as ® or ®, based on the physician's recommendation.
3. In the physician signature section, ensure that you or the physician sign and provide their PIC#, which is essential for verification.
4. Proceed to fill out the IV contrast screening section. Enter pertinent lab values such as BUN, creatinine, and creatinine clearance/GFR, selecting the source and providing the date as necessary.
5. Respond to the questions regarding prior experiences with contrast materials, medications like , and any pre-existing conditions such as heart disease or asthma. Indicate if there is a possibility of pregnancy.
6. In the comments section, provide any additional information that may be relevant to the healthcare provider.
7. Identify the source of the information provided by selecting whether it was obtained from the patient, a family member, or medical records. Record the name of the individual obtaining the information and the date.
8. Complete the venipuncture information section, if applicable. Record the date, number of attempts, time, site of venipuncture, and details of the individual performing the procedure.
9. Before finalizing, review all entries for accuracy. Once completed, you can save changes, download, print, or share the form as necessary.

Complete your CT Simulation Contrast Request & IV Contrast Screening Form online today for a smoother scheduling experience.