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Identification: I, _________________________________ (patient) or (patient representative for ______________________ _______________________________) authorize Dr.__________________________ to perform the following operation or procedure: Thrombolytic Therapy for Acute Myocardial Infarction_______________________________________ Additional providers include: ___________________surgical task________________________________________________ ___________________surgical task________________________________________________ 2. 3. The reasons and benefits of performing the operation or procedure would include but are not limited to: Dissolution of coronary clot in treatment of acute myocardial infarction or heart attack.__________ I understand alternatives to the procedures include but are not limited to: Rehabilitation____________________________ ____________________________________________________________________________________________________ I understand alternatives would include refusal of the operation or procedure. My physician has explained the risks and benefits of these alternatives to me, including refusal. 4. I understand that there are potential risks to any procedure that may include but are not limited to: infection, bleeding, and injury to nerves, blood vessels or other tissues, blood clots, heart attacks, stroke and pneumonia. These risks could be serious or fatal. Additional significant risks specific to this procedure may include but are not limited to: Uncontrolled bleeding, bleeding in the brain, severe neurological deficits, death. I understand that the procedure or operation may require(circle as appropriate): Conscious Sedation Regional/Local General Anesthesia Monitored Anesthesia Care None


I understand that conscious sedation will be administered by my physician who has explained the benefits and risks of conscious sedation. Risks may include reactions to the medications that could lead to serious heart or breathing problems and very uncommonly may lead to cessation of breathing or death. I understand that for any planned general or regional anesthesia an anesthesia provider will obtain consent. If the planned conscious sedation, monitored anesthesia care does not provide adequate sedation/analgesia an anesthesia provider from the Hospital may be requested to perform a deeper level of sedation to complete the planned procedure. 6. If my physician discovers a different, unsuspected condition at the time of surgery, I authorize him or her to perform such other procedures except for the following: _________________________________________ If none, write none. I understand that no guarantee or assurance has been made as to the results of the procedure and I understand that there is a chance it may not cure the condition. Complications and poor outcomes can occur and further treatment may be needed. I understand the doctor will appropriately dispose of removed tissues, parts or organs resulting from the procedure(s) authorized above. I consent to any photographing or videotaping of the procedures(s) that may be performed, provided my identity is not revealed by the pictures or by descriptive texts accompanying them so that my physician may follow my therapy progression. I consent to the admittance of students/residents or authorized equipment representatives to the procedure room for purposes of advancing medical education or obtaining important product information. 7. I have read this form or have had it read to me, I understand this information and have no further questions. ___________ Date ___________ Date ____________ Date ____________ Time ____________ Time ____________ Time ____________________________________ Patient / Patient Representative Signature ____________________________________ Hospital Staff / Witness Signature ____________________________________ Physician Declaration Signature ____________________________ Patient Representative Print Name

Physician declaration: I have discussed the contents of this form with the patient and have answered all of the patients questions regarding the operation or procedure.

Verde Valley Medical Center 269 South Candy Lane; Cottonwood, AZ 86326;928-634-2251 PATIENT INFORMED CONSENT FORM THROMBOLYTIC THERAPY FOR ACUTE MYOCARDIAL INFARCTION


Revised 01/30/13

CNS DocuPrint