Healthcare Cardiac Catheterization Lab Form

Cardiac Catheterization Lab Pre-Procedure and Consent Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance and Referral

Medical History and Current Status

Chronic conditions (check all that apply): Diabetes Hypertension Kidney disease COPD Heart failure

Height:    Weight:

Pre-Procedure Assessment

Indicated Procedure:

Vascular Access Site (select): Right radial Left radial Right femoral Left femoral

Anticoagulant / Antiplatelet therapy: Warfarin DOAC (apixaban, rivaroxaban, etc.) Heparin   Last dose/date:

Recent laboratory data available: Creatinine:    INR:    Date of labs:

Contrast allergy or prior reaction to contrast: Yes No    If yes, describe:

For women of childbearing potential: Pregnancy test performed: Yes No    Last menstrual period:

Risks, Benefits, and Alternatives

The cardiologist has explained that the indicated procedure involves catheter insertion into the arterial or venous system for diagnostic and/or therapeutic interventions. The anticipated benefits include diagnosis of coronary artery disease, relief of ischemia, restoration of blood flow and obtaining hemodynamic measurements.

Significant risks include, but are not limited to: bleeding or hematoma at the access site, vascular injury requiring additional procedures, stroke, myocardial infarction, arrhythmia, contrast-induced kidney injury, allergic reaction to contrast (which can be severe), need for emergency surgery, and death. Less common complications include infection, nerve injury, and blood transfusion.

Reasonable alternatives were discussed, including medical therapy, noninvasive testing, or no intervention. The patient has had the opportunity to ask questions and understands the information provided.

Consent and Authorization

I, the undersigned, authorize my physicians and such assistants as they may select to perform the cardiac catheterization and any associated diagnostic or therapeutic procedures as deemed necessary. I authorize the administration of sedation, analgesia and contrast agents as required for the procedure and any additional procedures that are necessary for my immediate care.

I authorize the transfusion of blood products if necessary in an emergency. I understand that despite all precautions, unforeseen events can occur and that no guarantee has been made to me concerning the results of the procedure.

I understand that I may withdraw consent at any time prior to the administration of sedation or local anesthesia and that withdrawal of consent may not be possible once the procedure has been initiated.

I have read or had explained to me the above information; my questions have been answered; and I voluntarily consent to the proposed procedure.

HIPAA and Release

I acknowledge receipt of the facility's Notice of Privacy Practices and consent to the use and disclosure of my protected health information for treatment, payment and healthcare operations related to this procedure. I authorize release of pertinent medical records and images to physicians involved in my care.

Pre-Procedure Checklist (to be completed prior to transport)

NPO (no food or drink) since:

IV access established: Yes No    Allergic status checked and documented: Yes

Required labs reviewed and acceptable: Yes    Pregnancy test (if applicable): Done

Interpreter / Special Needs

Interpreter required: Yes No    Language:

Patient Certification and Signature

By signing below, I certify that I have read and understand the information on this form, that the information I have provided is true and complete to the best of my knowledge, and that I consent to the performance of the procedure, administration of sedation and contrast, and other care as described above.

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