PICC Â LINE Â INSERTION Â INFORMED Â NURSING Â CONSENT
AND Â AGREEMENT Â FOR Â TREATMENT
ÂI agree to have a Peripherally Inserted Central Catheter (PICC) placed in my arm.
ÂThe catheter insertion procedure, care, maintenance and, complications have been explained to me and I understand them.
ÂI understand that this is not the only way I can receive my medication. I understand that my health care team has determined that the PICC line would be the safest and most effective means of giving my medication at this time.
ÂAlternative vascular access device options ________________________________________________ Â of giving my
medication have been explained to me and I have chosen this one.
ÂI realize this procedure will be performed only by a nurse who has been specially
trained and certified to insert PICC lines. Â
ÂMy catheter will be inserted by ____________________________.
ÂI realize that this is an invasive procedure and has certain risks such as catheter or air embolism, arterial puncture, infection, irregular heartbeat and venous thrombosis.
ÂI understand that while the catheter will be placed in my upper arm the end of the
catheter will come to rest in an area near my heart.
ÂI have the right to voice any questions I may have about this procedure and I expect knowledgeable answers.  I also understand that (Institution Name) has specific policies relating to the care which will be given to me and include provisions for termination of services at my request, the request of  physician, and/or at the decision of the agency.
ÂI agree to abide by the terms of these policies in all respects.
 Â__________________________                          _________________________
Patient Signature                                                                              Date
Â__________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __________________________
Witness                                                                                              Date
Â