Your doctor has recommended the removal of your venous access device.

Nature of Procedure:

Port-a-Cath removal involves the removal of the inserted catheter (tube)inserted from the large vein which was attached to a reservoir (port) that was 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. The Radiologist will then remove the port device that was placed beneath it beneath the skin. A dressing will then be applied to the area once the port is removed.

Risks and complications to the procedure that will be explained:

• Bleeding.
• Infection, which may require the use of antibiotics.
• Damage to nerves or blood vessels and 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:

• You have read, you understand, and you agree to the conditions of this document.
• The procedure described 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-Catheter procedure.
• You authorize and consent to the performance of the Port-a-Catheter 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.