Risk Management

Fluorescein Angiography Consent Form

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INFORMED CONSENT FOR FLUORESCEIN ANGIOGRAPHY
Patient:______________________________________________________________________________
1. I hereby authorize to administer intravenous Fluorescein and/or Indocyanine Green dye for the purpose of performing angiography.
2. Angiography is a diagnostic procedure in which a rapid sequence of photographs are taken to document the blood circulation of the retina/choroid. The dye is usually injected into a vein in the arm, forearm, or hand.
3. Since the fluorescein dye is a very bright yellow, the skin may appear jaundiced for a few hours and then the yellow color disappears. The dye is excreted through the kidney causing the urine to be bright yellow for 24-36 hours.
4. Indocyanine Green is excreted through the bile and will show in the stool as greenish. The coloration of these dyes are considered to be a normal result of the after effects.
5. Less than 0.2% of all patients to whom these tests are administered have any of the listed side effects. Documented adverse reactions to the dyes which can occur include: nausea, headache, upset stomach, vomiting, light-headedness, fainting, hives or itching.
6. Even more rarely, severe allergic reactions (anaphylaxis) or bronchospasm can occur and be life threatening. I have informed my physician of any allergies to foods, iodine, or medications. I have informed my physician if I have asthma.
Patient initials _____
7. Extravasation of the fluorescein dye out of the blood vessel is painful and every effort is made to prevent this from occurring.

FOR WOMEN:
8. Intravenous fluorescein/ICG is usually not administered to pregnant or nursing women, although there is no scientific evidence to suggest that it might harm the fetus or nursing babies.
To the best of my knowledge, I am not pregnant or nursing a baby.
Patient initials_______

PATIENT’S STATEMENT OF ACCEPTANCE AND UNDERSTANDING
9. I hereby authorize and direct and/or their designees to provide such additional services as they may deem necessary and reasonable.
10. I understand that no guarantees of any kind regarding these procedures have been made to me.
11. I consent to the use of the above photographs and other materials for scientific purposes, provided my identity is not revealed by the pictures or the descriptive text accompanying them.

Patient (or person authorized to sign for patient)__________________________________________________