Download Consent to Cardiovascular Procedures

PLACE LABEL HERE
CONSENT TO CARDIOVASCULAR PROCEDURES
Important: Do not sign this form without reading and understanding its contents.
The diagnosis requiring this procedure is: _________________________________________________________________________
1) General Information about Cardiovascular Procedures. Cardiac/Peripheral Catheterization involves the insertion of a small
hollow tube (catheter) into a vein or artery in the leg, groin, or arm and then threading it into the heart/peripheral arteries. This catheter
may be used to record pressures in your heart, to inject iodine based contrast medium into the heart/peripheral arteries to allow x-rays
to be made, or allow a balloon dilatation catheter to be inserted into a coronary/peripheral artery. These procedures are conducted
under local anesthesia. A brief description of these procedures with their indications follows.
2) Authorization. I hereby authorize _____________________________ and any such assistants and designees as may be selected
by him/her to perform the following procedure(s).

Cardiac Catheterization and Coronary Angiography
Performed for diagnosis of heart disease. Indications include: EKG changes, positive exercise test, chest pain, shortness of
breath, heart murmurs, or hemodynamic disturbances. It involves placing catheters into the left and often right side of the
heart to measure pressures, define coronary blockage and evaluate valves.

Coronary Artery Interventions (Balloon Angioplasty or Stenting)
Performed for the treatment of coronary artery disease. Involves inserting catheters through the artery or vein in the groin, leg,
or arm, injecting contrast medium and dilating/cutting/extracting/stenting atherosclerotic plaque within the coronary artery.

Carotid Artery Stenting
Performed for the treatment of carotid artery disease.

Peripheral / Carotid Angiography
Performed for the diagnosis of peripheral vascular disease. It involves placing catheters into the peripheral arteries to define
peripheral artery blockage.

Peripheral Intervention (Angioplasty/Athrectomy/Laser/Stent Insertion)
Performed for the treatment of peripheral vascular disease. Involves inserting catheters through the artery or vein in the groin,
leg, or arm, injecting contrast medium and dilating/cutting/extracting/stenting atherosclerotic plaque within the peripheral
arteries.
3) Known Significant Risks of These Procedures.
A. Bleeding / Dissection (tearing of artery or vein). Occasionally the artery or vein will ooze after catheterization resulting in a
hematoma or bruise. Severe bleeding which requires blood replacement (with associated risks of AIDS and/or hepatitis) or surgery
is extremely rare. Precautions are taken to minimize this risk but can occur despite these precautions.
B.
Infection. The procedure is performed using sterile technique. The rate of infection is less than 1%.
C.
Heart Attack and Stroke. Rare complications resulting from spasm or occlusion of the artery or arteries which supply the brain.
D.
Allergic Reaction. Most reactions are to the iodine based contrast media and are minor. If you have had a previous reaction to
“dye” or contrast or are allergic to seafood, notify the physician so that we may attempt to avoid a reaction by premedicating you.
E.
Artery Occlusion. A rare complication which may occur and sometimes necessitates immediate surgery.
F.
Rhythm Problems. Most rhythm disturbances occurring during cardiac cath are not serious. The Lab is well equipped to deal
with the rare, serious rhythm disturbances. The chances of these rhythm disturbances being untreatable are remote.
G. Necessity of Immediate Heart Surgery. Cardiac catheterization findings or the process of performing a coronary intervention
may necessitate immediate surgery.
H.
Death. Occurs in less than 1 out of 1,000 procedures.
I.
Catheter Break. Occurs very rarely but may necessitate surgical removal.
J.
Other medical risks generally recognized and accepted by reasonable prudent physicians are loss or loss of function of any
limb or organ, paralysis or partial paralysis, paraplegia or quadriplegia, disfiguring scar, brain damage or cardiac arrest.
K.
In addition to the above risks there may be other risks involved in this particular procedure such as: _______________
*3-21614*
FORM 3-21614 REV. 02/2012
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PLACE LABEL HERE
CONSENT TO CARDIOVASCULAR PROCEDURES
________________________________________________________________________________________________
*3-21614*
FORM 3-21614 REV. 02/2012
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PLACE LABEL HERE
CONSENT TO CARDIOVASCULAR PROCEDURES
4) It has been explained to me that during the course of the procedure, unforeseen conditions may arise that require an extension of
the original procedure(s) or different procedure(s) from that set forth in Paragraph 2. I, therefore, authorize and request that the above
named physician, his/her assistant or designees, perform such procedures as appear necessary and desirable in their exercise of
professional judgment. The authority granted under this Paragraph 4 shall extend to treating all conditions that require treatment and
are not known at the time the procedure is commenced.
5) I acknowledge and understand that this request for any consent to surgical or diagnostic services shall be valid for the responsible
physician, all medical personnel under the direct supervision and control of the responsible physician, and for all other medical
personnel otherwise involved in the course of treatment.
6) I acknowledge and understand that, in addition to the material risks of the procedure(s) listed in Paragraph 3 there may be other
risks attendant to the performance of the procedure(s) as there are with any surgical or diagnostic procedure.
7) The likelihood of success of the above procedure has been discussed.
 Yes
 No
8) Practical alternatives to this procedure have been discussed.
 Yes
 No
Comments: ___________________________________________________________________________________________
____________________________________________________________________________________________________
9) If I choose not to have the above procedure, my prognosis will be:
 Good  Fair  Poor  Unknown
Comments: ___________________________________________________________________________________________
____________________________________________________________________________________________________
10) I have no reason to believe I am pregnant.
 Yes
 No
 NA
11) I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been
made to me concerning the results of the procedure.
12) I understand that the cardiologist performing my procedure is not an agent or an employee of Gwinnett Medical Center, but is an
independent medical practitioner exercising independent medical judgment at facilities provided by Gwinnett Health System.
13) I consent to the administration of anesthesia by my physician and to the use of such anesthetics as may be deemed advisable. I
consent to the use of a direct arterial, central venous, or pulmonary artery catheters if my condition, or the nature of the procedure,
necessitates such.
14) I have been given ample opportunity to ask questions and any questions I have asked have been answered or explained in a
satisfactory manner.
15) I acknowledge and understand that the explanation which I have received may not be exhaustive and all inclusive and that other
more remote risks may be involved. However, the information which I had received is sufficient for me to authorize and consent to the
procedure.
16) Moderate Sedation. I understand that moderate sedation is the administration of a drug or drugs that will depress consciousness
during a surgical/diagnostic procedure. The risks of moderate sedation including, but not limited to, heart attack and cessation of
breathing, have also been explained to me, as have the alternatives to conscious sedation, which are the administration of local
anesthetics, oral pain medications or no sedation at all.
By signing this form I understand the above information regarding cardiovascular tests/procedures and acknowledge that I
have been fully informed of the risks and possible complications. If any unforeseen condition arises during the procedure
calling for additional procedures, operations, or medication (including anesthesia and blood transfusions), I further request
and authorize the physician to do whatever he/she deems advisable in my interest.
______________
__________________________ __________________ _________________________
Date/Time
Person giving consent
Relationship to patient
Patient unable to sign because of
___________ ______________ ___________________________________
___________
Date
PID Number
Time
FORM 3-21614 REV. 02/2012
Physician Signature
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