Patient Full Name: Date of Birth: Address: Contact telephone no.: Site identifier: a <Insert procedure name> is going to be performed. What will happen during the procedure? Provide a description of the procedure> < What are the risks? Insert an explanation of the possible risks here> < Patient health status can have a significant effect on the risks to a patient undergoing a procedure. Please list the indicators that may influence the risk of this procedure: Allergy/asthma status Diabetes status Kidney, heart, thyroid disease Pregnancy and/or breastfeeding status Medications that the patient is currently taking, including herbal and supplements Implanted medical devices such as pacemakers, stents and cochlear implants Previous reactions to contrast After the procedure - things you need to know. How the patient may feel Instructions for ongoing care after the procedure Instructions for reporting adverse effects The above information has been explained to me and I consent to the procedure: Name (Please print) Witness (please print) Signed Signed Date Date
Patient Full Name: Date of Birth: Address: Contact telephone no.: Site identifier: a <Insert procedure name> is going to be performed. What will happen during the procedure? < Provide a description of the procedure> What are the risks? < Insert an explanation of the possible risks here> Patient health status can have a significant effect on the risks to a patient undergoing a procedure. Please list the indicators that may influence the risk of this procedure: Allergy/asthma status Diabetes status Kidney, heart, thyroid disease Pregnancy and/or breastfeeding status Medications that the patient is currently taking, including herbal and supplements Implanted medical devices such as pacemakers, stents and cochlear implants Previous reactions to contrast After the procedure - things you need to know. How the patient may feel Instructions for ongoing care after the procedure Instructions for reporting adverse effects The above information has been explained to me and I consent to the procedure: Name (Please print) Witness (please print) Signed Signed Date Date
Appendix%2010%20-%20Template%20-%20Health%20status%20risk%20and%20consent%20form%20(D15-827359).DOCX