Informed consent for transesophageal echocardiography (TEE), a semi-invasive cardiac imaging procedure performed under sedation. Single signer (patient).
The Transesophageal Echocardiogram (TEE) 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, tee, echocardiogram, imaging, sedation. 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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# Transesophageal Echocardiogram (TEE) 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:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Description of the Procedure A transesophageal echocardiogram (TEE) is a cardiac ultrasound examination performed by advancing a thin, flexible probe through the mouth into the esophagus (food pipe) and stomach. Because the esophagus lies directly behind the heart, the probe provides high-quality, detailed images of the heart's structure and function that may not be obtainable from the surface of the chest (transthoracic echocardiogram). The probe is not a rigid instrument and does not enter the airways or lungs. **Indication for TEE:** ___________ **Sedation planned:** ___________ --- ## 2. Expected Benefits (a) High-resolution real-time imaging of heart structures including the mitral valve, aortic valve, left atrial appendage, atrial septum, thoracic aorta, and pericardium (b) Detection of thrombus in the left atrial appendage before cardioversion or ablation, reducing the risk of procedure-related stroke (c) Precise evaluation of valve anatomy and regurgitation severity to guide surgical or interventional planning (d) Identification of vegetations (infected deposits) on heart valves in suspected endocarditis (e) Guidance of transcatheter interventions in real time