Informed Consent Order Form - Neonatology

Patient Name: _____________________________________________________
Patient DOB: _____________________________________________________
Provider Name: _____________________________________________________

Please Obtain Informed Consent for the Following:

   Possible Only
Umbilical Cord - Catheterization of Umbilical Vein/Umbilical Artery (UVUA) (13623)
This procedure involves placing a long, thin catheter into an umbilical (belly button) vein (UVC) or artery (UAC). Sometimes, both UVC and UAC...

Additional Notes (include Anatomical Side/Location if Applicable):

Order Form Accurate Until 11/2/2021