Patient Information
Name: _________________________ Date of Birth: _____________
Medical Record #: ________________ Date: _____________________
1. SCOPE OF TREATMENT
Planned Procedure
- Primary procedure: _______________________________________
- Additional planned interventions: ___________________________
- Expected duration of hospital stay: __________________________
Pre-operative Requirements
- Completion of all required diagnostic tests
- Adherence to medication adjustments
- Participation in pre-operative education sessions
- Smoking cessation (if applicable)
2. PATIENT RESPONSIBILITIES
- Follow all pre-operative instructions
- Provide accurate medical history
- Disclose all current medications
- Attend all scheduled appointments
- Comply with post-operative care instructions
- Report any complications promptly
- Participate in cardiac rehabilitation as prescribed
3. PROVIDER COMMITMENTS
- Perform surgical procedure according to accepted standards of care
- Provide comprehensive pre- and post-operative care
- Maintain clear communication regarding treatment plan
- Respond to emergent complications promptly
- Coordinate with other healthcare providers
4. RISKS AND BENEFITS
Acknowledged Risks
- Surgical complications
- Anesthesia-related risks
- Recovery time variations
- Potential need for additional procedures
Expected Benefits
- Improvement in cardiac function
- Enhanced quality of life
- Reduction in cardiac symptoms
5. FINANCIAL RESPONSIBILITIES
- Insurance coverage verification
- Expected out-of-pocket costs
- Payment arrangements
- Additional service costs
6. SIGNATURES
Patient: _________________________ Date: ____________
Surgeon: _________________________ Date: ____________
Witness: _________________________ Date: ____________