HIDA Scan Consent Form

0323 - HIDA Scan Consent Form

Date of Test:(Required)

Time:(Required)

Hida Scan Instructions: Nothing to eat or drink for 4 hours prior to the exam. Wear comfortable clothes and shoes. You may continue your normal medications, which could be taken with a small amount of water or juice up to four hours prior to your study. Some medications are generally stopped for this test. This should be discussed with Dr. Suleman prior to the test. Drugs that can affect HIDA results:Reglan® (metoclopramide), Zelnorm® (tegaserod), erythromycin, and Motilium® (domperidone) and antispasmodics such as Bentyl®, Donnatal®, Levsin®, and Robinul®. Avoid narcotic medications such as Morphine, Percocet, Codeine, and Oxycontin 2-4 hours prior to the exam. Please check with your primary physician before discontinuing any medications. Do not take any laxatives on the day before or any time during your study. This exam will take around 1-2 hours. You will be able to drive afterwards (If you are able to drive yourself). Please call (214) 504-9942 if you have any questions regarding this procedure.

Consent for HIDA Scan: Your doctor would like you to have a HIDA scan (hepatobiliary iminodiacetic acid scan). The test is also referred to as a gallbladder scan and evaluates problems with the liver, gallbladder, and/or bile ducts. Bile is made by the liver and is used by the body to carry waste products out of the liver and to aid in the digestion of fats. Bile ducts are tubes that carry the bile from the liver to the gallbladder for storage until it is needed for digestion.

Female Patient Screening (applicable to females that are 11-55 years of age):

Is there any possibility you could be pregnant?

Yes

If "NO", please check appropriate:

Had a hysterectomy, tubal ligation, or post- menopausal?

Currently on birth control?

Your last menstrual cycle start within the last 14 days?

When was the date of your last menstrual period

Are you currently breast feeding?

Yes

No Show Responsibility:The HIDA involves us ordering dye that must be opened before you arrive. If you do not show up for this appointment, the medication will be unusable. Please give us 24-hour notice if you will not be able to make the appointment. If you do not show up for this appointment and no notification is received within 24 hours prior to the test, then we will be billing you for the cost of the nuclear medication ordered. The total cost of medication is $50. Please let us know if you have any questions regarding this policy.

**PLEASE NOTE, IF YOU HAVE MEDICAID OR ANY MEDICAID MANAGED CARE PLAN, THEY WILL NOT COVER THE DRUG FOR THIS TEST AND YOU WILL BE RESPONSIBLE FOR THE $50.00 UP FRONT**

I have read and understand the above information.

Patient Name:

Patient Signature

Witness

Date