Vascular Institute of Virginia
14085 Crown Court, Woodbridge, VA 22193
Phone (703)763-5224 Fax (703)763-5374
Place Patient Label Here
CONSENT FOR SPECIAL TREATMENTS OR PROCEDURES
I hereby authorize Anish Shah, M.D. and/or such associates and assistants as may be designated by (him) (her) to treat the
condition or conditions in connection with my visit with VIV. I authorize them to perform the procedures known as: Peritoneal
Dialysis Catheter Insertion, Evaluation, Repositioning and/or Removal, Peritoneoscopy, Peritoneography, Fluoroscopy
under conscious sedation.
The procedure(s) has/have been explained to me in laymen’s terms by Anish Shah, M.D.
I have been made aware of certain risks, hazards, complications and consequences that are associated with the above sedation and
procedure(s), as well as possible alternative modes of treatment
It has been explained to me that during the course of a procedure, unforeseen conditions may be revealed that necessitate an
extension of the original procedure(s) or different procedure(s) than those set forth in paragraph 1. I therefore authorize and
request that the above-named physician, his associates and/or assistants perform such procedures as are necessary and desirable
in the exercise of their professional judgment. The authority granted under this paragraph shall extend to treating all conditions
that require treatment and are not known to the physician performing the authorized procedure at the time the procedure is
commenced.
Possible risks associated with this procedure include, but are not limited to: Contrast and medication-related allergies, bowel
perforation, infection, bladder perforation, hematoma, hemorrhage, vessel damage or rupture, hematoma/bruising, air
embolism, infection and possibly death (Pt’s initial
).
I have also been informed that there are other risks including but not limited to severe loss of blood, infection and/or cardiac
arrest, which are attendant to the performance of any invasive procedure. I am aware that the practice of medicine and surgery is
not an exact science and I acknowledge that no guarantees or assurances have been made to me concerning the results of the
above procedure or treatment.
I further consent to disposal by VIV, in accordance with its accustomed practice, of any tissue parts that may be removed.
I also consent to the admittance of observers to the Procedure Room, and to the videotaping, photographing or televising of the
operation or procedure to be performed. This includes appropriate portions of my (the above patients) body for the purpose of
advancing medical or scientific purposes provided my (the above patient’s) identity is not revealed by either the pictures or the
descriptive text accompanying them.
I acknowledge and agree that I have had the opportunity to ask questions and that all my questions have been answered to my
total satisfaction.
When applicable, I consent to including the presence of a manufacturer’s representative for technical support and consultation
purposes. The manufacturers technical support representative will not touch or handle a device while it is being applied to a
patient.
When applicable, I consent to the release of my Social Security Number to the manufacturer, for the purpose of tracking
implantable devices, pursuant to the Safe Medical Device Act. I consent to the administration of such sedation as may be
considered advisable by the physician and/or their designees responsible for this service, with the exception of (circle NONE or
state any exception):
NONE
_____________________________________________________________________________________________
I acknowledge that I have been informed of the foreseeable risks, benefits, alternatives, to and possible consequences of the
proposed sedation. I am aware that unforeseen and unexpected results can occur during the administration of sedation.
I acknowledge that I have had the opportunity to ask questions and that all my questions have been answered to my total
satisfaction.
_______________________________
Signature
_____________________
Relationship
_______________________________
Witness
_____________________
Date
If an interpreter was utilized to obtain this consent, complete the following:
___________________________________
INTERPRETER – PRINT NAME
_________________________
INTERPRETER – SIGNATURE
___________________________________
INTERPRETER ADDRESS
_________________________
DATE
PHYSICIAN’S STATEMENT OF INFORMED CONSENT
I hereby have explained the nature, purpose, benefits, risk of and alternatives to the above procedure and sedation if needed.
And have fully offered to answer any questions. In addition, I have fully offered all such questions and believe that the patient
(relative/guardian) fully understands what I have explained and answered.
_____________________________
Physician’s Signature
_____________
Date
THIS DOCUMENT MUST BE MADE PART OF THE PATIENT’S MEDICAL RECORD, AND INVASIVE PROCEDURES
WILL NOT BE COMMENCED (EXCEPT IN CASES OF EMERGENCY) WITHOUT IT’S COMPLETION