Get Peripherally Inserted Central Catheter (picc) Line - Mayo Clinic

Filling out the Peripherally Inserted Central Catheter (PICC) Line consent form is an important step in your healthcare process. This guide provides clear and comprehensive instructions to help you complete the form accurately and confidently.

Follow the steps to complete the PICC Line consent form effectively.

1. Press the ‘Get Form’ button to access and open the PICC consent form in your document editor.
2. Begin by filling in your name on the line provided for 'I,_________________________________________________ , agree to have a peripherally inserted PICC catheter (PICC) inserted through a vein in my arm.' Ensure your name is printed clearly.
3. On the next line, indicate the name of your physician who has ordered the PICC catheter placement by filling in the space next to 'I understand my physician, Dr. _ __________________________________________ has ordered this catheter.'
4. Read through the description of the catheter placement process and ensure you understand the information provided regarding the risks and procedures involved.
5. In the section where it states 'My PICC will be inserted by______________________________________________________ .RN.', write the name or title of the nurse performing the insertion.
6. Take note of the list of risks associated with the PICC procedure. This section outlines potential complications such as air embolism and catheter infection. Review these critically.
7. Confirm your understanding of the procedure and risks by reading through the statement provided. Make sure you have all questions answered before proceeding.
8. Complete the 'Patient/authorized representative’s printed name' section by entering your name as it should appear.
9. Sign the consent form in the 'Patient/authorized representative’s signature' area, confirming your agreement to the procedure after fully understanding the information.
10. If applicable, fill out the 'Relationship if signed by person other than patient' section clearly, specifying your relationship to the patient.
11. Have the witness fill in their printed name and signature where indicated in the form.
12. Finally, complete the date and time sections at the bottom of the form before saving or printing the document.

Complete your PICC Line consent form online to ensure a smooth and informed procedure.