PERIPHERAL   IV   CATHETER    INSERTION 
INFORMED   NURSING   CONSENT
AND   AGREEMENT   FOR   TREATMENT

1.	I agree to the insertion and rotation of  peripheral IV catheters by a trained professional.

2.	The catheter insertion procedure, care, maintenance and, complications have been
	explained to me and I understand them.

3.	I understand that this is not the only way I can receive my medication. I understand that
	my health care team has determined that the peripheral IV catheter would be the safest 
	and most effective means of giving my medication at this time. Alternative vascular
	access device options ____________________________________________  of
	giving my medication have been explained to me and I have chosen this one.

4.	I agree that the peripheral IV catheter will be routinely change every 72 hours or
	whenever necessary. 

5.	I realize that this is an invasive procedure and has certain risks such as catheter
	infection, infiltration, extravasation, phlebitis and nerve damage.

6.	I understand that a catheter no longer than 1 1/2 inch  will be placed in my arm.

7.	I have the right to voice any questions I may have about this procedure and I expect
	knowledgeable answers.  I also understand that there are 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. I agree
	to abide by the terms of these policies in all respects.

___________________________			_________________________
Patient Signature								Date

___________________________			__________________________
Witness									Date