JFK Medical Center, Atlantis, FL 33462
CONSENT-PACEMAKER-DEFIBRILLATOR WITH LEAD
EXTRACTION OR REVISION-GENERATOR EXCHANGE
*TREAT* JFK-746-01146 Rev. 10/16 Page 1 of 2
CONSENT FOR PACEMAKER AND/OR DEFIBRILLATOR WITH
LEAD EXTRACTION AND/OR REVISION/GENERATOR EXCHANGE
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