ABC | Volume 114, Nº1, January 2019

Statement Position Statement of the Brazilian Cardiology Society and the Brazilian Society of Hemodynamics and Interventional Cardiology on Training Centers and Professional Certification in Hemodynamics and Interventional Cardiology – 2020 Arq Bras Cardiol. 2020; 114(1):137-193 I further declare that I have had the opportunity to read this document carefully and also to listen attentively to the physician’s reading of all the information presented herein, and I was able to clarify all of my doubts regarding the risks involved and the possible consequences of not performing the suggested treatment, as well as the possible existence of alternative procedures, and my doubts have been satisfactorily addressed and answered. I am aware that there is a possibility of alteration of the original procedure over the course of the aforementioned exam/procedure and/or new procedure or surgery for the sake of continuity of treatment in a different region from the one originally designated, which, if applicable, will be evaluated, decided upon, and performed, by the medical professional in charge, with which I now agree and hereby authorize. All my questions having been answered and having understood the procedure in and of itself, as well as its real repercussions, I sign this CONSENT FORM, in the presence of Dr. ................................................................................................................, who, in this act, represents the Hemodynamic Medical Service, together with 2 (two) witnesses, expressly and voluntarily declaring my authorization for the exam/procedure of coronary cineangiography with left ventriculography, FFR, or iFR and assessment of myocardial bridging, consenting, furthermore, to the performance of the proposed exam/procedure as well as its preparatory acts; the physicians are hereby authorized to performed additional procedures and therapeutic interventions that may become necessary due to unforeseen conditions which may occur during the course of the exam/procedure, remaining always at the discretion and judgment of the attending physician. For the purpose of promoting scientific development, by signing the present Consent Form, I further agree and authorize the performance of photography, video recording, or televised transmission of the proposed exam/procedure, being assured that my identity will not be revealed. I also authorize the examination of any organ or tissue eventually removed, which may be treated by the medical team and/or the hospital for medical, scientific, and educational purposes. Finally, I consent to the eventual possibility of a blood transfusion, should this procedure be directly linked to the treatment mentioned in this consent and authorization form or resulting from it. If, during or immediately after the performance of the exam/procedure which I am to undergo, I am not in full possession of my physical and/or mental abilities, I authorize my legal representative ..................................................................................... ..........................................., nationality ...................................................., marital status ......................................................., profession ....................................................., identity document .................................................., issued by ................................., CPF ..............................................................., resident of ................................................................................................... ..................................., city ................................................................, state ................., date of birth ........../........../.........., parents’ names........................................................................................................................................., relationship to patient ............................................................, to make decisions in my name. In this manner, I offer my full and free consent, and I authorize the performance of the exam/procedure of coronary cineangiography with left ventriculography, FFR, or iFR and assessment of myocardial bridging, explained herein, to be administered by the signing physician and his/her related medical team. In conclusion, I certify, that I have signed two copies of the present Form, one of which has been given to me. Center Location: .......................................... Date: ........../........../.......... Patient’s Name: ...................................................... Signature: .................................................. Representative: ............................................ Signature: ................................................... Physician’s Name: ................................................... CRM no.: .......................... Signature: .................................................. Witnesses: Name: ........................................................ Name: ........................................................ 161