SHRI VASANTRAO NAIK GOVERNMENT MEDICAL COLLEGE & SUPER
SPECIALITY HOSPITAL, YAVATMAL — 445001
INFORMED CONSENT FOR CORONARY ANGIOGRAPHY PROCEDURE
Patient Name: ......................... Age/Sex: .......... / ...............
Date: ........ / ........ / ........
Address: .................,................. ....................... ..................,....
Coronary Angiography is a diagnostic procedure used to visualize the coronary arteries (blood vessels
of the heart) using contrast dye and X-rays. A catheter is inserted through an artery in the wrist or
groin and guided to the heart, where contrast dye is injected to identify any blockages or
abnormalities.
Purpose of the Procedure is to diagnose:
• Coronary artery disease (blockages or narrowing of heart vessels)
• Cause of chest pain, breathlessness, or abnormal ECG
• Evaluate candidacy for further treatment (like Angioplasty or Bypass Surgery)
Possible Risks and Complications:
1. Minor bleeding or bruising at the catheter insertion site
2. Allergic reaction to contrast dye
3. Irregular heartbeat (arrhythmia)
4. Drop in blood pressure
5. Temporary or permanent kidney dysfunction
6. Heart attack (rare)
7. Stroke (very rare)
8. Artery dissection or perforation (very rare)
9. Death (extremely rare)
I, (Name:........................................................), hereby declare that:
• I have been informed in detail about the nature, purpose, benefits, and possible risks of the
Coronary Angiography procedure.
• I understand that this is a diagnostic procedure and depending on the findings, further
treatment may be required.I understand that in case of emergency, the treating team
may perform additional necessary procedures to save my life.
• I give my full and informed consent to undergo the Coronary Angiography procedure.
Patient's Signature:
Name and Signature of Guardian/ Relative:
Name of Doctor : ...................... .. ..
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2.
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4. Dye (Nephropathy)
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6. (Myocardial Infarction)
7. (Arterial Dissection / Rupture)
8.
9. (Ventricular arrhythmia)
SMRI VASANTRAO NAIK GOVERNMENT MEDICAL COLLEGE & SUPER
SPECIALITY HOSPITAL, YAVATMAL — 445001
INFORMED CONSEI'4T FOR CORONARY ANGIOPLASTY PROCEDURE
Patient Name: ............. Age/Sex: .......... / ...............
Date: ........ / ........ / ........
Address: .
Coronary Angioplasty (also known as Percutaneous Coronary Intervention or PCI) is a therapeutic
procedure to open narrowed or blocked coronary arteries using a balloon and possibly placing a stent. A
catheter is inserted through an artery in the wrist or groin, guided to the heart, and treatment is
performed using advanced imaging and equipment.
Purpose of the Procedure:
• Improve blood flow to the heart muscle
• Relieve chest pain (angina) or symptoms of heart disease
• Reduce the risk of heart attack
• Treat emergency heart attacks by restoring blood flow quickly
Possible Risks and Complications:
1. Bleeding, bruising, or hematoma at the catheter insertion site
2. Allergic reaction to contrast dye or medications
3. Damage to the artery (dissection or perforation)
4. Irregular heart rhythms (arrhythmias)
5. Blood clot formation in stent (acute thrombosis)
6. Restenosis (re-narrowing of the artery)
7. Heart attack during or after the procedure
8. Stroke (rare)
9. Kidney impairment due to contrast dye
10. Emergency coronary artery bypass surgery (CABG)
11. Death (rare but possible)
I, (Name: .,.,...................................................), herebv declare that I have been explained the need,
nature, benefits, and risks of Coronary Angioplasty (PCI) in a language I understand.I understand that
this procedure may involve the placement of one or more stents. I voluntarily give my consent to
undergo the Coronary Angioplasty (PCI) procedure.
Patient's Signature:
Name and Signature of Guardian/ Relative:
Name of Doctor :
Š\ND SUPER S#EČ(ALITY HOSPITAL, YAVATMAL - 445001
DEPARTMENT OF CARDIOLOGY
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Patient Name -..................................................................... Age/Sex -...... yrs/...:..
Performed by - Dr.Sandeep Chaurasiya MD,DM (Cardiologist) -"Go\d Medalist
Dr.Piyush Kalantri MD (Med) ,DM (Cardiologist)
Dr.Shriniwas Parchake MD (Med) ,DNB (Cardiologist)
Approach - ....................................
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SHRI VASANTRAO NAIK GOVERNMENT MEDICAL COLLEGE &
SUPER SPECIALITY HOSPITAL, YAVATMAL — 445001
INFORMED CONSENT FOR CORONARY ANGIOGRAPHY PROCEDURE
Patient Name: ........................................................................... Age/Sex: .......... / ...............
Date: ........ / ........ / ........
Address: ............................................................................................................................
Coronary Angiography is a diagnostic procedure used to visualize the coronary arteries (blood vessels
of the heart) using contrast dye and X-rays. A catheter is inserted through an artery in the wrist or
groin and guided to the heart, where contrast dye is injected to identify any blockages or
abnormalities.
Purpose of the Procedure is to diagnose:
• Coronary artery disease (blockages or narrowing of heart vessels)
• Cause of chest pain, breathlessness, or abnormal ECG
• Evaluate candidacy for further treatment (like Angioplasty or Bypass Surgery)
Possible Risks and Complications:
1. Minor bleeding or bruising at the catheter insertion site
2. Allergic reaction to contrast dye
3. Irregular heartbeat (arrhythmia)
4. Drop in blood pressure
5. Temporary or permanent kidney dysfunction
6. Heart attack (rare)
7. Stroke (very rare)
8. Artery dissection or perforation (very rare)
9. Death (extremely rare)
i, (Name:........................................................), hereby declare that:
• I have been informed in detail about the nature, purpose, benefits, and possible risks of the
Coronary Angiography procedure.
• I understand that this is a diagnostic procedure and depending on the findings, further
treatment may be required.I understand that in case of emergency, the treating team
may perform additional necessary procedures to save my life.
• Tgive my full and informed consent to undergo the Coronary Angiography procedure.
Patient's Signature:
Name and Signature of Guardian/ Relative:
Name of Doctor : . .. .........................................
SHRI VASANTRAO NAIK GOVERNMENT MEDICAL COLLEGE & SUPER
SPECIALITY HOSPITAL, YAVATMAL — 445001
INFORMED CONSENT FOR CORONARY ANGIOPLASTY PROCEDURE
Patient Name: ....................................................................................... Age/Sex: .. ....... /
...,........... Date: ........ / ........ / ........
Address: ............................................................................................................................
Coronary Angioplasty (also known as Percutaneous Coronary Intervention or PCI) is a therapeutic
procedure to open narrowed or blocked coronary arteries using a balloon and possibly placing a stent.
A catheter is inserted through an artery in the wrist or groin, guided to the heart, and treatment is
performed using advanced imaging and equipment.
Purpose of the Procedure:
• Improve blood flow to the heart muscle
• Relieve chest pain (angina) or symptoms of heart disease
• Reduce the risk of heart attack
• Treat emergency heart attacks by restoring blood flow quickly
Possible Risks and Complications:
1. Bleeding, bruising, or hematoma at the catheter insertion site
2. Allergic reaction to contrast dye or medications
3. Damage to the artery (dissection or perforation)
4. Irregular heart rhythms (arrhythmias)
5. Blood clot formation in stent (acute thrombosis)
6. gestenosis (re-narrowing of the artery)
7. Heart attack during or after the procedure
8. Stroke (rare)
9. Kidney impairment due to contrast dye
10. Emergency coronary artery bypass surgery (CABG)
11. Death (rare but possible)
I, (Name:........................................................), hereby declare that I have been explained the need,
nature, benefits, and risks of Coronary Angioplasty (PCI) in a language I understand.I understand that
this procedure may involve the placement of one or more stents. I voluntarily give my consent to
undergo the Coronary Angioplasty (PCI) procedure.
Patient's Signature:
Name and Signature of Guardian/ Relative:
Name of Doctor : ...............................................
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High-Risk Consent ( -
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/ COPD / Bronchial Asthma 9 (Diabetes)
Stroke / Paralysis @
/ Mechanical Support (IABP/ECMO)
\s) L) Ventilator / ICU@
Coronary Angiography ) Complications
1) Heart Rate / .)
2) BP
3) Drug Reaction Angiography / Angioplasty Contras Dye .
4) Bleeding (TdFfR(4) - / / Motion .)
5) Heart attack ) H 28 TPH .
6) .
7) Patient Unstable Incomplete .
8) Nephropathy / H .
9) Coronary Angiography / Angioplasty .
10) Procedure W / .
