Download special consent for cardiovascular procedures

JERSEY SHORE MEDICAL CENTER
SPECIAL CONSENT FOR
CARDIOVASCULAR PROCEDURES
Patient:______________________________________ Date:_______________________
am
Time:________________________pm
1.
I hereby authorize Kenneth B. Harris, M.D., Joshua B. Winslow, M.D., and Edward Choi, M.D.
(“Physician”) or other members of Jersey Shore Medical Center (the physician members of his medical
group) and such assistants as may be selected, including resident physicians, to treat the following
condition(s) and to perform the procedure(s) described below:
Cardiac Catheterization, Coronary Angiography, Ventriculography, Possible Percutaneous Coronary
Angioplasty, Rotation Ablation, Intra-Aortic Balloon Pump Insertion, Percutaneous Coronary Stent
Placement, emergency open heart surgery if necessary.
2.
The procedure(s) necessary to treat my condition has/have been explained to me by
Dr._________________________ and I understand the nature of the procedure to be:
Insertion of catheters or tubes into the artery to inject dye/contrast into the heart and the arteries of the
heart. Insertion of an inflatable balloon, shaver or cutting device or metallic scaffolding into arteries to
repair blockages.
3.
I have indicated to the physician that I do not wish to know the details of my case or the proposed
treatment or diagnostic procedure(s). I trust his/her professional judgment to do what is best for my
care and treatment. I hereby designate__________________________as a person with whom my
physician may consult as he/she deems advisable in deciding upon the course of treatment.
4.
It has been explained to me that, during the course of the procedure, unforeseen conditions may be
revealed that necessitate an extension of the original procedure(s) than those set forth. These
procedures include: angioplasty and related interventional procedure(s) as well as coronary bypass
surgery. I, therefore, authorize and request that the above named Physicians, their assistants, or their
designees perform such surgical or other procedures as are necessary and desirable in the exercise of
professional judgment. The authority granted under this paragraph shall extend to treating all
conditions that require treatment and are not known to the above named Physicians at the time the
operation or other procedure(s) commenced..
5. It has been explained to me that there are alternatives to the aforementioned course of treatment,
including but not limited to:
Medications or no therapy
6. Physician has further explained to me the risks and consequences commonly associated with the
procedures described above, including but not limited to, injury to arteries, nerves, veins adjacent
structures, and there is also the possibility of loss of blood, loss of limb, stroke, infection, cardiac
arrest, fatal reactions to radiographic contrast material, and intracardiac manipulation, although
extremely rare, may occur. In addition to the above risks, I understand that a potential complication of
angioplasty may require emergency bypass surgery. I understand the risks of bypass surgery, includes,
but is not limited to, heart attack, heart failure, stroke, vascular injury, infection and death. 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 operation or procedure. I also have been made
aware of what could happen if I choose not to have this procedure performed.
7. The physician has discussed the anesthesia options and risks with me prior to the procedure.
8.
I certify that I have read and fully understand the above consent to the diagnostic or operative
procedure(s): That all blanks and statements requiring insertion or completion were filled in and
paragraphs which I do not wish apply, if any, were stricken before I signed.
_____________________________
Witness to Signature
__________________________________
Signature of patient or person responsible
____________________________
Witness to Signature
__________________________________
Relationship to Patient
PHYSICIAN’S CERTIFICATION
I,_________________________________ MD, certify that I have explained the specified operation(s)
or procedures, the use of anesthesia, the attending risks and consequences, the alternatives and the
prognosis if the operation or other procedures is not performed, to the above named patient and/or
other responsible person who has signed the above consent.
Date:______________________
________________________________,MD
Signature