Healthcare Vascular Tab

HEALTHCARE VASCULAR TAB

Patient Information

Date of Birth:    Gender:    Medical Record No.:

Primary Phone:    Alternate Phone:

Insurance

Policy Number:    Group Number:    Subscriber Name:

Presenting Complaint & History

Onset Date:    Duration / Course:

Claudication / exertional leg pain    Rest pain    Non-healing wound/ulcer    Extremity coldness   

Swelling/edema    Varicose veins    Skin discoloration/cyanosis    Other:

Medical & Surgical History

Current or prior smoker    Diabetes mellitus    Hypertension    Hyperlipidemia

Coronary artery disease    Chronic kidney disease    Prior stroke/TIA    Family history of vascular disease

Vascular Examination (to be completed by clinician)

Diagnostic Studies

Ankle-Brachial Index (ABI) Right:    Left:

Wound / Ulcer Specifics (if applicable)

Procedure Consent for Vascular Evaluation / Treatment

I authorize my healthcare team to perform vascular diagnostic and/or therapeutic procedures as indicated, including but not limited to duplex ultrasonography, angiography, endovascular intervention, thrombolysis, angioplasty, stenting, and surgical revascularization. The procedure(s) to be performed and the clinical indications will be documented in the medical record and explained to me prior to the procedure.

I understand the significant risks associated with vascular procedures may include bleeding, hematoma, infection, contrast reaction, kidney injury from contrast exposure, arterial dissection or perforation, distal embolization, acute limb ischemia, need for conversion to open surgery, stroke, myocardial infarction, limb loss, and death. I acknowledge that not all risks can be listed here and that my clinician will discuss risks specific to my condition and procedure.

Benefits may include improved blood flow, relief of ischemic pain, wound healing, limb salvage, and improved function. Reasonable alternatives, including conservative management, medical therapy, or alternative procedures, will be discussed with me.

I acknowledge that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction. I understand that I may withdraw consent at any time prior to the procedure and that withdrawal of consent may not be possible once sedation or anesthesia, or invasive access, has been initiated for safety reasons.

Yes    No

Privacy & Authorization

By signing below I acknowledge receipt of the facility's privacy practices and authorize disclosure of my vascular health information to other treating clinicians and entities involved in my care as necessary for treatment, payment, and healthcare operations. I authorize release of relevant diagnostic images and reports to other providers and facilities as clinically indicated.

Additional Notes / Instructions

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