PICC  LINE  INSERTION  INFORMED  NURSING  CONSENT
AND  AGREEMENT  FOR  TREATMENT

1.	I agree to have a Peripherally Inserted Central Catheter (PICC) placed in my arm.

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 PICC line 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 realize this procedure will be performed only by a nurse who has been specially
	trained and certified to insert PICC lines.  
	My catheter will be inserted by ____________________________.

5.	I 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.

6.	I 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.

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

__________________________			_________________________
Patient Signature							Date

__________________________			__________________________
Witness								Date