General Add On 
 Add On for *DATE*
 
Patient (age)
MR#
Wt:
Diagnosis:
Procedure:
Attending:
Approved by:
Anesthesia or local:
If GA time added:
NPO status:
HCG:
Guardian available for consent:
Other: (inpatient, fluid orders, relevant allergies, etc.)
 
 
Vascular Access Add On 
 Add on for *DATE*
 
Patient (age)
MR#
Wt:
Diagnosis:
Procedure: [PICC placement, PICC exchange, Tunneled CVL, Port]

• Has pt been evaluated by VAS?
• If exchange: does patient have other IV access (this is required)?
• Any anatomic restrictions or special considerations (cardiac, renal, h/o thrombosis, short gut)?
• # of lumens -
• Power injectable? (4Fr is smallest DL and 3Fr for SL)
• Ethanol lock? (Intestinal failure/short gut patients. Single lumen only)

Attending:
Approved by:
Anesthesia or local:
If GA time added:
NPO status:
HCG:
Guardian available for consent:
Other: (inpatient, relevant allergies, etc.)
 
 
G to GJ Add On  
G to GJ Add-on
 
Patient (age)
MR#
Weight:
Diagnosis:
Procedure: G conversion to GJ
When was G originally placed:
Size of G:
Guardian available for consent:
Attending:
Approved by:
 
 
GJ Add On 
GJ Tube Add On for *DATE*
 
Patient (age)
MR#
Weight:
Diagnosis:
Procedure:
Why GJ being replaced:
Last changed/size of GJ:
Consent valid?:
Attending:
Approved by: