This customizable document, Peripherally Inserted Central Catheter (PICC, Consent Form, is taken from MCN Healthcare’s Home Infusion Therapy Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

MCN’s templates save you time, money and resources, rather than developing healthcare policy and procedure manuals from scratch.

Here is some sample content from Peripherally Inserted Central Catheter (PICC, Consent Form:

	PERIPHERALLY INSERTED CENTRAL CATHETER PICC Name of Client: Your physician has decided that a peripherally inserted long line catheter PICC may be advantageous in providing IV medication or solution for treatment of your medical diagnosis. CONSENT FORM With my consent, an agency PICC Certified Registered Nurse will place a PICC line in my arm and thread it through my vein. The tip or end of this catheter may lie in a location in a vein between my upper arm PIC and the large vein superior vena cava above the right side of my heart PICC, depending on the judgment of the Registered Nurse, and...
Second excerpt:
	...and include, but are not limited to, soft tissue injury, phlebitis vein inflammation, thrombus/embolus catheter fragments or blood clots which may be stationary or mobile, infections and bleeding. I am also aware that I am to be given instructions on the steps to reduce these risks specific to my therapy and ways to recognize the dangers associated with PICC. I recognize that in the insertion of this catheter, there may be unknown risks. My signature below indicates that: I have read the...