Healthcare Cardio Elite Consent Form

HEALTHCARE CARDIO ELITE CONSENT FORM

This Healthcare Cardio Elite Consent Form documents the patient's informed consent for the proposed diagnostic or therapeutic cardiovascular procedure or treatment. The patient acknowledges that the proposed procedure, associated anesthesia (if any), and ancillary treatments have been explained, including the nature, purpose, anticipated benefits, material risks, and reasonably available alternatives. The patient understands that no guarantee has been made regarding outcome.

Patient Information

Patient Name:   Date of Birth:   Gender:

Insurance Information

Medical History

Check all current conditions that apply:

Hypertension    Diabetes    Prior Myocardial Infarction    Heart Failure

Arrhythmia    Stroke/TIA    Pacemaker/ICD    Chronic Lung Disease

Procedure / Treatment

Treating Physician:   Estimated Duration:

Risks, Benefits and Alternatives

I acknowledge that the physician has explained the anticipated benefits, material risks, and reasonably available alternatives, which may include medical therapy, alternative procedures, or no treatment. Material risks specific to cardiovascular procedures may include, but are not limited to: bleeding, infection, cardiac arrhythmia, myocardial infarction, stroke, vascular injury, need for emergent surgery, loss of limb, renal injury, allergic reaction to medications or contrast, and death.

Patient Initials to Confirm Discussion of Risks:

Anesthesia, Blood Products, and Additional Treatments

I consent to administration of local, regional, or general anesthesia as required for the procedure. I authorize the treating team to administer blood products and related interventions if medically necessary and life–preserving. I understand that complications related to anesthesia or transfusion may occur.

I consent to anesthesia if required: Yes   I consent to blood transfusion if necessary: Yes

Patient Rights and Withdrawal of Consent

The patient has the right to ask questions, receive answers, and to withdraw consent at any time prior to the initiation of the procedure. Withdrawal of consent after initiation of the procedure may not be possible without risk. If the patient revokes consent, the treating team will document the revocation and discuss alternative options to the extent feasible.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with or offered a notice describing the health care provider's privacy practices. I authorize the healthcare team to use and disclose my protected health information to the extent necessary for treatment, payment, and health care operations, including communication with other treating providers and family members as discussed with me.

I acknowledge receipt of the privacy notice: Yes

Authorization to Release/Obtain Medical Records

Certification and Consent

By signing below, I certify that I am the patient or authorized representative. I confirm that the information I have provided is true and complete to the best of my knowledge. I have read (or this form was read to me), understand the explanation provided, and have had an opportunity to ask questions which were answered to my satisfaction. I voluntarily consent to the procedure, anesthesia, and related care described above.

If signed by an authorized representative, documentation of authority (e.g., power of attorney, guardianship order) must be presented upon request and will be retained in the medical record.

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