Cardiac Procedure Informed Consent Form

Patient Information

Name: _________________________
Date of Birth: __________________
Medical Record #: _______________

Procedure Details

Proposed Procedure: _____________________________________________ Side/Location (if applicable): ____________________________________

Consent Declaration

I, _________________________, hereby authorize Dr. _________________________ and associates to perform the following cardiac procedure(s):

• Primary procedure: ________________________________________________
• Additional procedures (if necessary): _________________________________

Risk Acknowledgment

I understand that this procedure carries the following risks:

Common Risks (>1%)

• Bleeding or bruising at procedure site
• Infection
• Pain or discomfort
• Allergic reactions to medications or contrast dye

Serious Risks (<1%)

• Cardiac arrhythmias
• Heart attack
• Stroke
• Need for emergency surgery
• Death (rate varies by procedure)

Alternative Treatments

I understand the following alternatives have been discussed:

1. Medical management
2. Modified procedures
3. No treatment

Patient Confirmation

I confirm that:

• All my questions have been answered satisfactorily
• I understand the risks and benefits
• I have had sufficient time to make this decision
• I am signing this document voluntarily

Signatures

Patient/Guardian: _____________________ Date: _________ Time: _________

Physician: __________________________ Date: _________ Time: _________

Witness: ____________________________ Date: _________ Time: _________

Interpreter (if applicable)

Name: ______________________________ Date: _________ Time: _________