$2 Fortis Memoriat Patents Name: Cit Vandiqnue RESEARCH INSTITUTE uo pooguoluy wo Cone £4689 age :__ 40 Gender : Male 1 Female DOA men ee Ue wed INFORMED CONSENT FOR TEMPORARY DIALYSIS CATHETER INSERTION A. Alifiekls must be completed bythe person explaining the consent. Mork NA if fel ex rev Fe eaeenvcr formation pleore see the PATIENT INFORMATION UTERATURE i provided) of SB80k With your Doctor. PARTA 1. Full Name of the procedure: Temporary Dialysis Catheter Insertion 2. Details of procedure: Dialysis is an artificial means to perform the function of the kidneys, through a series of filters and semipermeable ‘membranes. Hemodialysis Is the process of filtering blood and requires vascular access {access through blood vessel). ‘A Temporary Dialysis Catheter Placement procedure is specially designed plastic tubing incerted ina large vein, commonly near the neck or groin used to perform hemodialysis Common reasons for performing a Temporary Dialysis Catheter Placement procedure include: © Acute kidney failure . Chronic kidney disease requiring dialysis = Patient requiring plasmapheresis 3. Alternative choice: There are permanent alternatives for dialysis access, such as an arteriovenous fistula or peritoneal dialysis; however, neither of these options can provide an immediate access, nor replace @ temporary catheter 4, Benefits of ei . eerorary dialysis catheter can provide immediate access fora dialysis . ‘The catheter may also be used for ‘blood draws’ 3 5, Complications of the procedure: ce amage to central veins, including injury, bleeding and hematorns Centra er coted blood), which ean lead to pressure effect on nearby vessels end airway can occur during placement of dialysis catheter mg complications- During the dialysis catheter insertion iy) Pulmonary or lu } ‘can occur, including- procedure, a number of lung related complications 2 Leary betwen the ning f the lungs andthe chest activity krown as preumat causing underlying lung collapse. Scanned with CamScanner= anu \_— Pawion —_Handiyno _, [] meraennor Ch —oertae of patient Tey etn ete ear enin above eno) ost 8 Deen explained this consent form in _ENEALIGH-] EE LAVPL_ (name of tangunee) wich | understand, and understood =the ~—sinformation provided stout amet name of operation/ procedure im Part A ofthis consent form: J am now aware of the intended benefits, possble rks & complications, and avaiable atematives (oO 28 results of any operation/procedure can vary from patient to patient; and | Geclare ‘exarding sucess ofthis operation/procedure. 1am aware that while majority Of ind recovery, few cates may be associated with complications. | am aware of the caer ats and complications associated with this operation/procedure as sted In Part A, and understand that tis nok ‘possibe to lit al possible risks ané complications of any operation/pracedure, patients have an uneventful operation a {alto understand that sometimes a planned operation/procedure may need tobe postponed or canceled if patients cna) cation worsens or due to any unforeseen technical reason. | arn also aware that | can withdraw my consent at any pain of e ‘ume at my own risk and consequence, by submitting the withdrawal in writing. ‘carried out, and in such case there may be difference in ‘require administration of blood and/or blood products, doctor (for which a separate consent shall be obtained). the planned and actual operation/procedure. | am aware that 'may ‘during oF after the operation/procedure as found necessary by the | am now alto avare that duting the course of this operation/procedure the doctor will be assisted toy medical arvi poramedical team, and that the docter may seek consultation/assistance from relevant specialists if the need arises. | agree to observing, photography (stilvideo/televising) of the procedure (including relevant portions of my body) including Giagnosis/reports (pathology, my radiology, etc), for academic) medical/medico legal purposes, provided my identity is not oe i aah taig iret ioe ca ooo erect in Rat 0 Scanned with CamScannerabnormal heart \8) Cardiac or héart complications: Cardiac complications SUCH 9 TG cardiac ‘or akiough tare or complete shutdown ofthe heart, #9 arrest, may occur during placement of dialysis catheter W) Device dysfunction- Potential complications from device = Thrombosis or blood clot = Cracking or breaking of the catheter itself _ = Obstruction of the catheter ¥)_Infection- Central venous line infections become known as biofiim collects on the Internal and/or external bacteria that are commonly found on the skin's surface dysfunction include Scanned with CamScannermade aware of, | give my consent voluntary to For the ‘above mentioned operation(s\/procedure(s) that | have been me in tne cpeaon/proceue) fo Or. [name of crf rh eaves [E] OTA or cove red vant bata wert inert, ote iss and complications, intended bene and poste aeratives. | the above named Patient/named patient's representative, do further hereby the date of signing this form, mentally sound and am giving consent without any feat, Signed ok 7/4) 12 _ at §_:30amyem declare that | am above 18 years of age a on threat or false misconception. Scanned with CamScannerqs a“ sr