Download Informed Consent to Electrophysiology Procedures

PLACE LABEL HERE
INFORMED CONSENT TO
ELECTROPHYSIOLOGY PROCEDURES
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
Important: Do not sign this form without reading and understanding its contents.
The diagnosis requiring this procedure is: _________________________________________________________________________
1)
General information about Electrophysiology Procedures:
2)
Authorization: I hereby authorize___________________________________ and any such assistants and designees as may
be selected by him/her to perform the following procedures:
 Diagnostic Electrophysiology Study is a procedure that allows for an accurate assessment of heart electrical
activity. Special catheters are inserted into the heart through veins/arteries located in the leg. This allows the
physician to detect any electrical abnormalities of the heart.
3)

Therapeutic Ablation is a study that uses a special catheter to deliver energy to the precise area of the heart that is
causing the abnormal heartbeat. The tip of the catheter destroys small areas of tissue, therefore interrupting the
abnormal rhythm

Cardioversion is the restoration of the heart’s rhythm to normal by electrical countershock or pharmaceutical means.
Known Significant Risks of These Procedures:
Fainting; very fast or very slow heartbeat; infection; loss of blood; pain; allergic reaction or blockage of a groin blood
vessel requiring an emergency surgical procedure to restore circulation. A very small percentage of patients who have the
above procedures performed develop more serious complications such as heart attack, heart failure and rarely paralysis
or loss of a limb, stroke, or death. The complications and risks of ablation procedures also include the possibility of
myocardial perforation, which may require a procedure for drainage or rhythm disturbances requiring the implant of a
permanent cardiac pacemaker, and rarely open heart surgery.
Use of Blood Products
  I understand the risks and possible need for use of blood products and consent to the administration or transfusion of
blood or blood products to me during my procedure and/or its related treatment whenever deemed necessary by those
physician(s) attending to me, with no warranties made in connection with such blood or blood components.
Photographs/Observers
  I consent to the taking of photographs, videotaping or other recordings in the course of this procedure for the purpose of
advancing medical education as may be authorized by my physician(s) and to the admittance of qualified observers to the
operating/procedure room as determined by the hospital.
Medical Device
To comply with the provision of the State Medical Act of 1990, I consent to the release of my social security number for tracking
purposes.
Contrast Media
I understand the risks and consent to administration of contrast media (dye) during specific diagnostic procedures whenever
deemed necessary by the physician(s) attending to me. I assume all risks in connection with use of contrast media that include, but
are not limited to, allergic reaction, nausea, thrombophlebitis, hives, or renal failure. Very rarely an asthmatic attack, fall in blood
pressure, or cardiac arrest can occur and medical treatment may be required to correct these conditions. In extremely rare
conditions, a fatal reaction has occurred.
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.
*2-36629*
FORM 2-36629 INITIATED 04/2014
Page 1 of 2
PLACE LABEL HERE
INFORMED CONSENT TO
ELECTROPHYSIOLOGY PROCEDURES
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
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 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.
13) I have been given ample opportunity to ask questions and any questions I have asked have been answered or explained in a
satisfactory manner.
14) 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.
15) 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
_______________________________
(Reason patient is unable to sign)
Responsible Practitioner’s Statement:
I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed procedure, with the patient or the
patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask questions.
___________
Date
_______________
Time
FORM 2-36629 INITIATED 04/2014
__________________________________
Physician Signature
_______________
PID Number
Page 2 of 2