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Rancho bernardo advanced imaging

Offices: Mission Viejo, Ladera Ranch and Laguna Woods PATIENT INSTRUCTIONS for
GLUCOPHAGE ® (METFORMIN) and IODINATED CONTRAST MATERIAL
Name: _______________________________________ DOB: __________________
You are having a procedure today that may include the injection of iodinated contrast material
(x-ray dye). Additionally, you have indicated that you are currently taking the medication
Glucophage® (Metformin). The following is important information for you to know:

Metformin (Glucophage) is an oral antihyperglycemic agent used to treat patients with
noninsulin-dependent diabetes. There is an uncommon but serious adverse effect of lactic
acidosis, possibly leading to death, in patients who do not discontinue their Metformin
medication following injection of contrast material.
Metformin (Glucophage) must be discontinued after the contrast injection, and withheld for 48
hours after the injection. It should only be reinstated after you have had a blood test and the
results have been reviewed and approved by your personal physician.
Trade Names: Gluocophage, Fortamet, Glumetza, Riomet, Glucovance, Metaglip, ActoPlus
Met, Acto Plus MET, Prandimet, Avandamet, Janumet
If you have any questions regarding this medication interruption or the management of your
diabetes during this time period, please contact your personal physician.
I have read and understand these instructions.
Signature of patient: ___________________________________ Date: __________________
Witness: ____________________________________________ Date: ___________________
REFFERRING PHYSICAN: _______________________________________
FAX NUMBER: _______________________________
FAXED BY: ____________________ DATE: ______________ TIME: ______________
24301 Paseo De Valencia Suite 100 27725 Santa Margarita Parkway, #101 Offices: Mission Viejo, Ladera Ranch and Laguna Woods “DO NOT COMPLETE THIS FORM UNLESS YOU ARE TAKING ORAL
GLUCOPHAGE® (METFORMIN)”

Name: _______________________________________ DOB: __________________
You are having a procedure today that may include the injection of iodinated contrast material
(x-ray dye). Additionally, you have indicated that you are currently taking the medication
Glucophage® (Metformin).
I have read and understand these instructions.
Signature of patient: ___________________________________ Date: __________________
Witness: ____________________________________________ Date: ___________________
REFFERRING PHYSICAN: _______________________________________
FAX NUMBER: _______________________________
FAXED BY: ____________________ DATE: ______________ TIME: ______________
24301 Paseo De Valencia Suite 100 27725 Santa Margarita Parkway, #101

Source: http://www.ocdiagnostics.net/pdf/100.%20Glucophage%20form.pdf

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Sindarin-kurs (lektion 1-5)

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