Winnipeg, Manitoba, Canada

Angiography Forms


Left-click to view in Adobe Acrobat, right-click to Save As.
Open with Acrobat version 7 or higher.
Don't have Adobe Acrobat? Download it for free here:

 
Note: Patients with Advance Care Plan – Medical Care

As with most procedures done on the heart, there are risks with having a coronary angiogram/angioplasty. Although the risk is low, the procedure may cause an arrhythmia that is most often successfully managed with defibrillation. Patients with Advance Care Plan – Medical Care, (ACP - M) status must at minimum be willing to accept defibrillation peri-procedurally to manage such an arrhythmia. The referring physician is to address with the patient and document as a progress note. In the event the patient refuses defibrillation and the referring physician believes the patient would benefit from the procedure, the referring physician should speak directly with the Interventional Cardiologist.

 
INPATIENT REFERRAL
   
  Cardiac Catheterization Referral Form (2016)
  New Cardiac Catheterization Referral Memo (2016)
  SBH/HSC Pre-Angiogram / Angioplasty / Stent Checklist (2015)
  Coronary Catheterization Aspirin (ASA) Allergy Referral Form (2016)
  Physician Order Sheet - Pre-Coronary Angiogram / Angioplasty / Stent Procedure (2015)
  Physician Order Sheet - Post-Coronary Angioplasty / Stent / GPIIb IIIa Inhibitor Infusion (2015)
  Physician Order Sheet - Post-Coronary Angiogram Procedure (2015)
  Pre-Coronary Angiogram / Angioplasty / Stent Transfer Notice Form (2012)
   
OUTPATIENT REFERRAL
   
  Cardiac Catheterization Referral Form (2016)
  New Cardiac Catheterization Referral Memo (2016)
  Elective Angiography Information Checklist (2016)
  Anticoagulation Pre-Angiogram Thrombotic Risk Form (2014)
  Coronary Catheterization Aspirin (ASA) Allergy Referral Form (2016)
  WRHA Cardiac Surgery Referral Form (for TAVI) (2015)
 
   
RESOURCES
 
  If you have an ASA allergy - what you need before your cardiac (heart) procedure brochure
  ASA allergy Primary Care Provider information letter
   
 
 

© 2017 WRHA Cardiac Sciences Program, Winnipeg, Manitoba, Canada

Updated 12/07/17

Translate

 

free hit counter code