Form # Mcg294 - Brachial-Basilic Av Fistula (2013)

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Georgia Regents Medical Center
Patient Label
INFORMED CONSENT FOR SURGICAL
AND/OR DIAGNOSTIC PROCEDURES
Date: _____________ Time: _____________
Year
(Military Time)
Month/Date/
1. I, ____________________________________, understand and acknowledge that I am to undergo the following procedure(s):
[Printed Name of Patient or Guardian]
________________________________________________________________________________________________________
Placement of brachial-basilic transposed upper arm arteriovenous fistula
2. This procedure is to be performed by: ______________________________________________________________________
[Name of Primary Practitioner]
I further understand that my physician may be assisted during this procedure by other physicians or practitioners whom he
designates; and who may assist or perform portions of the procedure(s) at the request or under the direction of my physician.
3. I understand that the purpose of this procedure is: _____________________________________________________________
Provide permanent access for hemodialysis
4. I understand that this procedure involves certain risks. These may include risk of infection, allergic reaction, disfiguring scar,
severe loss of blood, loss of function of any limb or organ, paralysis, brain damage, cardiac arrest, or death. In addition to these
risks,
there
may
be
other
possible
risks
as
a
result
of
this
procedure,
including,
but
not
limited
to:
________________________________________________________________________________________________________
Failure of fistula to work, bleeding, clotting of fistula, wound infection, steal of blood from hand with numbness/weakness of
________________________________________________________________________________________________________
hand
5. I acknowledge and understand that during the course of the procedure(s) described above, it may become appropriate to
perform additional procedures which are unforeseen or not known to be needed at the time this consent is given. Therefore, I
hereby consent to and authorize Georgia Regents Medical Center (GRMC), its medical staff and those other medical personnel
selected by GRMC to make decisions concerning the performance of such procedure(s) as they deem reasonably appropriate in
the exercise of their professional judgment. This consent shall also extend to the treatment of all conditions which may arise
during the course of such procedures including those conditions which may be unknown or unforeseen at the time this consent is
given. If conditions permit, an attempt to notify an authorized family member of changes occurring in the operating room will be
made.
6. I understand that if I do not undergo this proposed procedure(s), my prognosis is: ____________________________________
7. I understand that the practical alternatives to this procedure include:
________________________________________________________________________________________________________
8. I authorize GRMC to dispose of any severed tissue, organs, or body parts in accordance with the law and with GRMC policies.
9. I also consent to diagnostic studies, tests, anesthesia, x-ray examinations and any other treatment or courses of treatment
relating to the diagnosis or procedures described herein. A separate informed consent document may be required prior to some of
these procedures.
10. If a medical device is implanted in me, I authorize GRMC to provide the manufacturer of such implanted device with my
name, address, telephone number, and social security number for implant tracking purposes.
11. I understand that GRMC is an academic medical center with education as an integral part of its mission. Consequently, I
authorize the presence of students and other observers for educational purposes during my procedure.
12. I authorize the taking and publication of photographs or films (including videotape and television monitoring) of the
procedure(s) subject to the following conditions:
a.
that said photographs, films, or video be used only for purposes treatment and/or for the purposes of education and
research both internal and external to GRMC, and
b.
that the above described use and disclosure may continue without expiration except and unless I rescind authorization for
such use and disclosure in writing, and
c.
that the name of neither me nor my family will be used to identify said photographs, films, or videotapes.
13. I understand that I have the right to ask questions and I hereby certify that I have been given the opportunity to ask questions
and that any such questions have been answered or explained to my satisfaction.
14. I understand that no guarantees, assurances, or promises have been made to me concerning the results of this procedure.
*CONSENT*
Rev. 8/8/13; Form # MCG294
Page 1 of 2
CONSENT

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