Your doctor has recommended the procedure described below, as you need a venous access device. This will enable you to get needed medications and/or fluids.

Nature of Procedure:

Port-a-Cath insertion involves a placement of a catheter (tube) inserted into a large vein which is then attached to a reservoir (port) that is placed beneath the skin. The procedure starts with cleansing the skin with betadine. The Radiologist will inject local anesthetic into the skin, which may cause a stinging or burning sensation. A needle is inserted into the subclavian vein (behind the collarbone) or jugular area (in the neck). A guide wire is inserted under fluoroscopy (x-ray) and the catheter is inserted into the superior vena cava, a large vein that takes blood back to the heart. The Radiologist will attach the catheter to the port and place it beneath the skin. A dressing will then be applied to the area once the port is inserted in place.

Risks and complications to procedure that will be explained:

• Bleeding
• Infection, which may require the use of antibiotics
• Damage to nerves or blood vessels, surrounding structures
• Pain after surgery, which may require you to take pain medication.

Aftercare:

• No exercise or heavy lifting for the next three (3) days following procedure.

Waiver & Consent

By your confirmation below, you authorize and direct:

to remove your port-a-catheter. Your signature below further constitutes that:

1. You have read, you understand, and you agree to the conditions of this document.
2. The procedure set forth above has been adequately explained to you, you have had the opportunity to ask questions, and you have received all the information you desire concerning the Port-a-Cath procedure.
3. You authorize and consent to the performance of the Port-a-Cath procedure and any anesthesia required in connection with such procedure.

Witness Confirmation

By clicking the "Confirm" button, you acknowledge that Apex Radiology has electronically witnessed this consent form. The date and time of submission are recorded and securely stored as part of your medical record.