Healthcare Cardiology Document

HEALTHCARE CARDIOLOGY DOCUMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other/Prefer not to say

Insurance Information

Medical & Cardiac History

Hypertension
Diabetes
Congestive heart failure
Chronic kidney disease
COPD / Respiratory disease

Angioplasty (PCI)
Stent placement
Coronary artery bypass graft (CABG)
Valve surgery
Pacemaker / ICD
Ablation / Electrophysiology study
Other:

Chest pain or pressure
Palpitations
Syncope or near-syncope
Shortness of breath
Lower extremity swelling

Proposed Procedure / Consultation

I authorize the cardiology team to perform the following:

Indications for the proposed procedure:

Risks, Benefits, and Alternatives

The physician has explained the nature and purpose of the proposed procedure, the expected benefits, and the reasonably foreseeable risks which include but are not limited to: bleeding at the access site; vascular injury; hematoma; infection; allergic reaction to contrast or medications; contrast nephropathy and worsening renal function; arrhythmia requiring treatment; myocardial infarction; stroke; need for emergency surgery; need for blood transfusion; temporary or permanent disability; and death. These risks are not all-inclusive but represent material risks associated with the procedure.

Reasonable alternatives (including no procedure) and their associated risks and benefits were discussed, including medical therapy, continued observation, and other diagnostic options. I have had the opportunity to ask questions and understand that not all complications can be anticipated.

I consent to administration of sedation or anesthesia as deemed necessary, and to administration of contrast agents if required. I understand that if an unanticipated condition arises during the procedure, additional procedures necessary for my care may be performed by the attending physician.

Blood Products and Emergency Care

If clinically necessary, I authorize transfusion of blood and blood products and emergency interventions appropriate to address complications. I understand that attempts will be made to contact my listed emergency contact unless the situation precludes delay.

HIPAA & Privacy Authorization

I acknowledge receipt of the facility's Notice of Privacy Practices and authorize release of my protected health information to persons or entities involved in my care and payment for services, as necessary. I authorize the cardiology team to share procedure reports, results, and verbal communications with my emergency contact listed above and with my referring providers.

I acknowledge that I have received and understand the privacy practices and consent to release of my health information as described above.

Patient Declarations and Certifications

I certify that I have read and understand the information on this form, that the above information is true and accurate to the best of my knowledge, and that the proposed procedure, risks, benefits, and alternatives have been explained to me in terms I understand. I understand that I may withdraw my consent at any time prior to the procedure.

Yes — an interpreter is required for effective communication

Provider Information

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