Consent form centralvenouscatheter

CVC consent

1. NEW YORK CITY
HEALTH AND HOSPITALS CORPORATION

INFORMED CONSENT FOR
INVASIVE, DIAGNOSTIC
MEDICAL & SURGICAL
PROCEDURES

(Patient Imprint Cars)
FORM B-1
Thereby pet "(Name o tending Physician or Authorzed Heath Care Provider or

Inter Atsouste Atondng Physician othe same sar, And assets as maybe Ste and spend by hmmer pao
‘he folowing medeal eatmant operation, or procodue rereahar calle he procure:

‘The procure ha boon explained 1 mo and have been tol to reasons why ns he procedure The risks ofthe rocade have
alto bean explaned tome. In aden, have Deen ad Hate procedure may not have th rn ha expect Ihave ls been ed
Abou ihr posse weatmant orm cordon and what might happen no atmen eceod

‘understand atin ation othe rks deserbad to mo abet his procedure there ar iss hat may occur wit any surgealor
‘dea procera | am ana hal he pacte of mescine and surgery no an exact sence, anal have na bon van any
‘uaraioes about the reset lt proceda.

1 have ad enough ine 10 68648 my condon and esime wit my heat care providers an al of my uestons have been
ansnered to my sachen. seva) have enough inirmation fo make an sored deen an age ave ne procedure
Hramelng erpecednapgen a owed addons teen vents) Hon o name Loge, 2900 rs ay

| ago to hav varstusons o blood and ther blood product that may bo nacossary along wth tho procuro am having. The
ts bones and alernabvs have Deen explain to mo and alll my quostons hav boon arsed 1 my sation
1 rec o have ranstsions I wil ers out and inital hi section and sign à REFUSAL OF TREATMENT form.

Lago to low his fact to kop, use or proper dispose ol, eue and pas organ ha are removed during this procedure.

Signatur of Patent or PareniLegal Guardian of Minor Patent Da

the paint cannot consent or hirer, the signature o or the hal caro agent olga guardan who i ig on bea o
the pabon orto patents nox of kin who ascon othe aiment In part Must be Blanes.

‘Signature ot Wealth Cave Agence Guarda Date
{Bises a copy ofthe auhoraing document in

‘Signature & Relation of Next oFKin

WSS:

1 am afacity empoyee who is noto patente physician or authorizes
"ai Gare ERA above and have ARE pa e or appropiate person valuta sgn he om

“Signatur and Tie of Witness

TNTERPRETERTRANSLATOR: (10 Do signodby Vo OU Nr 111 paren QUES CN AA

To bo best ot myhnowiodge to pain! understood what ws inerrotorarsated ang voluntary nes is fom.

‘Signature Sopas

2. INFORMED CONSENT
PROGRESS NOTE Ward No.
lore Cs 5 8

hno