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 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 procedure of angioplasty with lower limb artery stent implantation, consenting, furthermore, to the performance of the proposed 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 procedure, remaining always at the discretion and judgment of the attending physician. 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 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 procedure of angioplasty with lower limb artery stent implantation, 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: ........................................................ 187