Heart Catheterization Form

Patient & Procedure Details

Last Name

First Name

Your Clinic/Hospital

Physician Performing Procedure

Procedure to be Performed

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Procedure Location

Date of Procedure

Arrival Time

Facility's Phone Number

Coumadin/Warfarin

Eliquis/Xarelto/-xaban

Insulin-Long Acting

Insulin-Short Acting

Metformin

Sulfonylureas

ED Medications

GLP1 Agonist/-tide

SGLT2 Inhibitors/-flozin

- Do NOT eat or drink anything after midnight before procedure.
- DO take any of your regular medications the morning of procedure unless advised otherwise.
- Your family will be shown to the waiting room and will receive periodic updates.
- The physician will talk with you or your family after the procedure.

Call the office if...
- any questions regarding procedure	- you develop an infection that requires antibiotics of any kind
- there is any change in your condition	- you develop a fever, cold, or flu symptoms
- are prescribed new medications