JFK Medical Center, Atlantis, FL 33462
*TREAT* JFK-746-01146 Rev. 10/16 Page 1 of 2
Patient Identification/Label
DOCTOR(S) ________________________________________________________________________________________and/or
physician associates has/have discussed my medical problem with me and has/have explained the following procedure(s) to be undertaken
in lay terms completely understandable to me. I understand that my physician/surgeon may designate assistants, associates, residents,
interns, technical assistants, and other health care providers as deemed necessary to assist him/her with the procedure(s) listed below.
Implant of Pacemaker and Lead Insertion
Implant of Automatic Defibrillator and Lead Placement
Implant of Biventricular Pacemaker
Implant of Automatic Defibrillator with left ventricular lead placement for biventricular Pacing
Pacemaker Generator Exchange
Automatic Defibrillator Generator Exchange
Pacemaker and/or Defibrillator lead Extraction
1. I have been fully informed and understand the potential benefits, risks and side effects of this care and also the likelihood of achieving goals related to this
procedure. Any potential problems that might occur during recuperation have been explained to me. I have also been informed about reasonable alternatives
and the risk of not receiving this procedure.
2. I have been fully informed of and understand the complications and the medically acceptable alternative(s) to the above-describe procedure(s). These
risks or complications may include but not limited to:
Fainting; Very fast or very slow heart; Infection; Loss of blood; Pain; Allergic reaction; or Perforation of the blood vessel or other
damage to the arteries requiring an emergency surgical procedure to restore circulation. A very small percentage of patients who have
the above procedures performed develop more serious complications such as Heart Attack; Heart failure; and rarely paralysis or loss of
a limb; stroke; or death. Pericardial Effusion with may require surgical drainage/intervention.
3. I understand that my physician may discover other or different conditions which may require different procedures than those planned. If any unforeseen
condition should arise during the course of the procedure, I do hereby authorize and request that the physician/surgeon and such associates, technical
assistants, and other
health care providers take whatever steps necessary to perform whatever procedure(s) they deem advisable, which may be in
addition to or different from those now
planned and have been discussed with me.
4. I have been made fully aware and acknowledge that the practice of medicine and surgery is not an exact science and that no guarantees or assurances
have been made to me regarding expected outcomes. Although this procedure and its complications have been explained to me, I acknowledge that I have
been given no guarantee against
complication or assurance of success from the physician who explained the procedure to me. I know I have been given
free choice to accept or reject any or all of the above procedures to be performed.
5. I consent to the proposed procedures(s) by the above physician(s) and (their) associates
Use of Blood Products
I understand the risks and possible need for use of blood products and I DO / DO NOT (Circle One) consent to the administration
or transfusion of blood or blood products to me during my procedure and/or its related treatment whenever deemed necessary by
those physician(s) attending to me, with no warranties made in connection with such blood or blood components.
Disposal of Tissue
I consent to the disposal by hospital authorities of any tissue, parts, organs, or extremities/limbs that may be removed in connection
with my procedure(s). Tissues and/or organs, no longer needed for diagnostic purposes, may be used and/or photographed for
research and educational purposes at JFK Medical Center, and its teaching facilities or for publication in an article related to medical
research for the purpose of medical education.
I consent to the taking of photographs, videotaping or other recordings in the course of this procedure for the purpose of advancing
medical education as may be authorized by my physician(s) and to the admittance of qualified observers to the operating/procedure
room as determined by the hospital.
Medical Device
To comply with the provision of the Safe Medical Act of 1990, I consent to the release of my social security number for tracking
Contrast Media
I understand the risks and consent to administration of contrast media (dye) during specific diagnostic procedures whenever deemed
necessary by the physician(s) attending to me. I assume all risks in connection with use of contrast media that include, but are not
limited to, allergic reaction, nausea, thrombophlebitis, hives, or renal failure. Very rarely an asthmatic attack, fall in blood pressure, or
cardiac arrest can occur and medical treatment may be required to correct these conditions. In extremely rare conditions, a fatal
reaction has occurred.
I have read and understand all of the above, have had an opportunity to ask questions concerning my planned procedure(s), and my
questions have been answered to my satisfaction
See below
Signature of Patient Print Name Date Time
If patient is unable to consent or is a minor, complete the following: Patient is unable to consent because
Signature of Authorized Representative Print Name Date Time
Relationship to Patient
Witness (Signature &Title) Print Name Date Time
I hereby certify that the patient or one authorized to act on his/her behalf;
1. Has been fully informed by me or my physician associates, in lay terms understandable to the patient, the nature of the procedure(s),
the medically acceptable alternative(s) to treatment, including refusal, and the consequences and risks to the patient inherent to or
associated with the procedure(s); and the likelihood of the patient achieving his/her goals.
2. Has authorized the performance of the procedure(s).
Physician’s Signature Print Name Date Time
JFK Medical Center, Atlantis, FL 33462
*TREAT* JFK-746-01146 Rev. 10/16 Page 2 of 2
Patient Identification/Label
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