Consent for Permanent Pacemaker Insertion

Procedure Name

Structure (Sidebar Reorder)

Section 1

Hospital/Facility Name

Attending Physician

Patient Name

Date of Birth

MRN / ID Number

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Section 8

Patient / Representative Signature

Physician Signature

Witness Signature

Date and Time

Consent for Permanent Pacemaker Insertion

Clinical & Administrative Information

Hospital/Facility Name

Attending Physician

Patient Name

Date of Birth

MRN / ID Number

Nature and Purpose of Procedure

A permanent pacemaker is a small electronic device implanted under the skin, usually just below the collarbone. One or more wires (leads) are placed through a vein into the heart chambers to monitor and regulate heart rhythm.

Material Risks and Complications

Bleeding, hematoma, or infection at the site of the pacemaker.

Pneumothorax (collapsed lung) during lead placement.

Lead displacement or fracture, requiring repeat procedure.

Cardiac perforation or pericardial effusion.

Device malfunction or technical failure.

Reasonable Alternatives

Alternatives may include medical management with drugs, lifestyle changes, or other types of rhythmic support. In some cases, there may be no viable alternative to maintain a safe heart rate.

Risks of Refusing Treatment

Choosing not to proceed may lead to worsening symptoms (fainting, fatigue), heart failure, or sudden cardiac arrest due to excessively slow heart rates.

Anesthesia and Sedation

This procedure is typically performed under local anesthesia and intravenous sedation. Risks include allergic reactions, respiratory depression, and rare cardiovascular events.

Patient Acknowledgment and Right to Refuse

I confirm that the procedure, its risks, benefits, and alternatives have been explained to me. I understand I have the right to refuse or withdraw consent at any time prior to the procedure. I also consent to the involvement of qualified medical residents or students under supervision, unless otherwise specified.

Signatures and Verification

Patient / Representative Signature

Physician Signature

Witness Signature

Date and Time

Document ID: CC-PENDING

CONSENTCOLLECT