Informed consent for implantation of a permanent pacemaker, implantable cardioverter-defibrillator (ICD), or cardiac resynchronization therapy device (CRT-P/CRT-D). Single signer (patient).
The Pacemaker / ICD Implantation Informed Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, cardiology, pacemaker, icd, crt, implant. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Pacemaker / ICD Implantation Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Facility Name:** ___________ **Performing Physician (Electrophysiologist / Cardiac Surgeon):** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Description of the Device and Procedure **Device to be implanted:** ___________ **Planned implant approach:** ___________ **Implant site:** ___________ **Anesthesia:** ___________ A pulse generator (battery pack) will be placed under the skin. One or more electrode leads will be threaded through the veins into the heart chambers (or, for subcutaneous devices, tunneled under the skin). The leads sense the heart's electrical activity and deliver pacing pulses or therapeutic shocks as programmed. --- ## 2. Indication / Medical Reason This device is recommended because: ___________ --- ## 3. Expected Benefits