Healthcare Patient Heart and Lung Document

HEALTHCARE PATIENT HEART AND LUNG DOCUMENT

Patient Information

Patient Name:    Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History — Heart & Lungs

Please indicate current or past diagnoses (check all that apply):

Hypertension    Hyperlipidemia    Diabetes    Coronary artery disease / prior MI    Heart failure

Arrhythmia / atrial fibrillation    Pacemaker / ICD    COPD    Asthma    Recurrent pneumonia

Chest pain    Palpitations    Shortness of breath    Syncope or fainting    Peripheral edema

Smoking status: Current smoker Former smoker Never smoker

Planned Evaluation, Tests and Procedures

Requested evaluation or procedure (check all that apply):

Echocardiogram (transthoracic / transesophageal)    Cardiac catheterization    Stress test    Pulmonary function test

Bronchoscopy    Chest CT / CTA    Other

Consent, Risks, and Authorizations

I authorize the medical staff to perform the indicated examinations, diagnostic tests and procedures necessary to evaluate and treat my cardiac and pulmonary condition. I understand that these may include monitoring, intravenous access, administration of contrast agents, sedation, local or general anesthesia, and other ancillary procedures as required.

I acknowledge that the following risks, while uncommon, are possible and have been explained to me: bleeding, infection, allergic reaction to medication or contrast, arrhythmia, myocardial infarction, stroke, pneumothorax (collapsed lung), respiratory failure, need for emergent surgery, permanent injury, or death. I understand that the exact risk profile depends upon the specific procedure and my underlying medical condition.

Alternatives to the proposed evaluations and treatments have been explained, including the option of foregoing the procedure and pursuing conservative management. I have had the opportunity to ask questions and all questions were answered to my satisfaction. I understand that I may withdraw consent at any time prior to the procedure without compromising my right to future care, except as limited by applicable law.

I authorize release of my protected health information, including relevant cardiovascular and pulmonary records, to other treating clinicians, referring providers, and my insurance carrier for purposes of treatment, payment, and health care operations. This authorization includes release of imaging, procedure reports, and pathology results if applicable.

I understand that some procedures may require the use of iodinated contrast or other agents that carry a risk of allergic reaction or kidney injury. I confirm that I have disclosed any known allergies, prior adverse reactions to contrast, and any kidney disease.

HIPAA & Privacy Acknowledgment

I acknowledge that I have received and reviewed the facility's notice of privacy practices describing how my health information may be used and disclosed. I understand my rights regarding my protected health information and that I may request restrictions or an accounting of disclosures in writing.

By signing below I consent to the uses and disclosures described above and authorize the release of information necessary for treatment and billing. I also consent to communication by telephone or electronic means for scheduling, results, or billing unless I specify otherwise.

Electronic and telephone communication consent: SMS/text messages Email Phone calls

I am signing as: Legal guardian Healthcare proxy / power of attorney Other representative

Acknowledgment and Certification

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that failure to disclose relevant medical history may increase the risk of complications. I consent to the performance of the specified tests and procedures and authorize those treating clinicians to provide necessary care related to my heart and lung condition.

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