Intravenous Fluorescein Angiography (IVFA) Consent Form

PROCEDURE

Intravenous Fluorescein Angiography (IVFA)

DESCRIPTION OF PROCEDURE

Intravenous Fluorescein Angiography (IVFA) is a diagnostic procedure used to examine the blood vessels in the retina. A fluorescent dye (fluorescein) is injected into a vein in my arm, and as the dye travels through the blood vessels of my retina, a special camera takes photographs. This test helps the doctor assess the health of the retina and diagnose and manage various eye conditions.

BENEFITS

The goal of this procedure is to:

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• Help diagnose retinal diseases, such as diabetic retinopathy, macular degeneration, and retinal vascular occlusions.

• Identify abnormalities in retinal blood vessels.

• Guide treatment decisions, such as laser surgery.

• Monitor the progression of retinal diseases.

ALTERNATIVES

There are no alternatives that will provide the same type of information for my doctor.

RISKS AND COMPLICATIONS

I understand that, as with any medical procedure, there are risks and potential complications associated with IVFA. These include, but are not limited to:

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• Common Side Effects:

  • Temporary nausea: Feeling sick to your stomach.

  • Yellowish skin discoloration: Your skin may appear slightly yellow for a few hours.

  • Orange urine: Your urine will be a bright orange color for up to 24-36 hours.

• Injection site reactions:

  • Pain or burning: At the injection site.

  • Bruising: At the injection site.

  • Extravasation: Leakage of dye outside the vein, which can cause localized pain, swelling, and, rarely, skin damage.

• Allergic reactions:

  • Mild reactions: Itching, rash, or hives.

  • Severe reactions (rare): Anaphylaxis, which can cause breathing difficulties, low blood pressure, and other serious symptoms.

• Other rare complications:

  • Fainting (vasovagal reaction)

  • Cardiac complications

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I have been informed about the material risks that are specific to my circumstances.

ACKNOWLEDGEMENT OF UNKNOWN RISKS

I understand that it is not possible or reasonable to predict or explain every possible risk or complication that may occur.

POST-PROCEDURE CARE

I understand that I will need to follow my physician's instructions carefully after the procedure. This may include:

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• Drinking plenty of fluids.

• Reporting any unusual symptoms, such as severe itching, rash, or difficulty breathing, immediately.

AUTHORIZATION OF ADDITIONAL PROCEDURES IN UNFORESEEN CIRCUMSTANCES

I understand that during the procedure, unforeseen or unknown conditions may be discovered that require additional or different procedures than those initially planned. I authorize the above-named healthcare provider, or their designate, to perform such additional procedures that, in their professional judgment, are immediately necessary and desirable to address these conditions, and where delaying such procedures would not be in my best interest.

CONSENT TO ANESTHESIA AND MEDICATIONS

I consent to the administration of appropriate anesthesia and all other medications deemed necessary to facilitate the treatment.

REGULATORY CONSIDERATIONS

I understand the Intravenous Fluorescein Angiography (IVFA) procedure may be considered off label in certain circumstances by regulatory agencies, such as Health Canada.

CONFIRMATION OF UNDERSTANDING

I have had the opportunity to ask questions about the procedure, its alternatives, risks, and benefits. I believe I have received enough information to make an informed decision. I voluntarily consent to the Intravenous Fluorescein Angiography (IVFA) procedure described above.

RIGHT TO WITHDRAW CONSENT

I understand that I have the right to withdraw my consent at any time before the procedure begins.

ACKNOWLEDGEMENT

I acknowledge that no guarantees have been made to me as to the result of the procedure(s).