Interventional Radiology Patient Intake Form

The interventional radiology patient intake form is a specialized pre-procedure document designed to collect the clinical information required for safe planning and execution of image-guided minimally invasive procedures. Interventional radiology encompasses a broad range of diagnostic and therapeutic procedures including angiography, embolization, percutaneous biopsies, tumor ablations, stent placements, drain insertions, and vascular access procedures. Each of these interventions carries specific risks related to contrast media exposure, bleeding, infection, and sedation that must be assessed before the procedure. The form ensures that interventional radiologists and their care teams have a complete clinical picture to guide procedure planning, risk mitigation, and patient preparation protocols.

The form captures detailed information about contrast media allergy history, including the type of reaction experienced and any premedication protocols previously used. Renal function data is collected to assess the risk of contrast-induced nephropathy, with specific questions about creatinine levels, dialysis status, and history of kidney disease. Anticoagulation and antiplatelet medication use is documented with dosages and last administration dates, which is critical for determining whether medications need to be held before the procedure. The form also records previous IR procedures and their outcomes, vascular access history including any complications, implanted devices such as pacemakers or metallic implants that may affect imaging modality selection, and current medications that could interact with sedation agents. Referring physician information and the specific procedure indication are captured to ensure proper coordination of care.

This form is used by hospital interventional radiology departments, outpatient imaging centers, vascular intervention clinics, and interventional oncology practices. It supports compliance with the Society of Interventional Radiology practice guidelines and Joint Commission requirements for pre-procedure patient assessment. The structured intake process allows IR teams to identify high-risk patients early, arrange appropriate premedication for contrast allergies, coordinate anticoagulation management with referring physicians, and ensure that informed consent discussions address patient-specific risks. For busy IR suites handling multiple procedures daily, the form reduces delays caused by missing clinical information and supports efficient scheduling by flagging patients who require additional preparation or monitoring resources.

Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Interventional Radiology Patient Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.