Your physician has ordered a Nuclear Gated Blood Pool Scan also known as a MUGA.  This is an examination used to evaluate the pumping action of the heart.  The test will involve the placement of an intravenous line in your arm.  You will receive two injections through this line.  The first injection called “Pyrophosphate” is a non-radioactive material used to tag your red blood cells.  Approximately 30 minutes later, you will be given a second injection call “Technectium-99m;” this is the radioactive isotope. Your heart will be scanned using a special camera.  You will be attached to an ECG monitor and three images of your heart will be taken.  Each image takes approximately 5 minutes. The amount of radioactive isotope injected is small and according to current scientific knowledge, free of hazard, except during pregnancy.  You understand that if you are or maybe pregnant or are breast feeding, you should not undergo this test procedure because of possible adverse effects to the fetus or baby

Participant’s Statement

I have read this consent form, discussed the procedure and I have been given the opportunity to ask questions, which have been answered to my satisfaction. I have been fully informed of the above described procedure with its risks and benefits, and I hereby consent to the procedure set forth.