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Heart Catheterization Form
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Patient & Procedure Details
Last Name
First Name
Your Clinic/Hospital
Physician Performing Procedure
Procedure to be Performed
Quick Add:
Cath w/ PCI
Right Heart Cath
PCI
Procedure Location
Date of Procedure
Arrival Time
Facility's Phone Number
Medication Checklist
Coumadin/Warfarin
No
Yes
Eliquis/Xarelto/-xaban
No
Apixaban
Betrixaban
Edoxaban
Eliquis
Xarelto
Insulin-Long Acting
No
Basaglar
Inuslin Glargine
Insulin Degludec
Insulin Detemir
Lantus
Levemir
Toujeo
Tresiba
Insulin-Short Acting
No
Novolin
Regular(R)
Velosulin (For Insulin Pump)
Metformin
No
metformin-pioglitazone (Actoplus Met, Actoplus Met XR)
Metformin-alogliptin (Kazano)
metformin-canagliflozin (Invokamet)
metformin-dapagliflozin (Xigduo XR)
metformin-empagliflozin (Synjardy)
metmorfin-ertugliflozin (Segluromet)
metformin-glipizide
metformin-glyburide (Glucovance)
metformin-linagliptin (Jentadueto, Jentadueto XR)
Metformin
metformin-repaglinide (PrandiMet)
metformin-rosiglitazone (Avandamet)
metformin-saxagliptin (Kombiglyze XR)
metformin-sitagliptin (Janumet, Janumet XR)
Glumetza
Riomet
Sulfonylureas
No
gliclazide
glimepiride (Amaryl)
glimepiride-pioglitazone (Duetact)
glipizide
glipizide ER (Glipizide XL, Glucotrol XL)
glipizide-metformin
glyburide (Glynase)
glyburide-metformin
ED Medications
No
Avanafil/ Stendra
Cialis
Sildenafil
Tadalafil
Vardenafil
Viagra
GLP1 Agonist/-tide
No
dulaglutide (Trulicity)
exenatide (Byetta, Bydureon)
liraglutide (Victoza, Saxenda, Xultophy)
lixisenatide (Adlyxine, Soliqua)
semaglutide (Ozempic, Wegovy, Rybelsus)
tirzepatide (Mounjaro)
SGLT2 Inhibitors/-flozin
No
canagliflozin (Invokana)
dapagliflozin (Farxiga)
empagliflozin (Jardiance)
ertugliflozin (Steglatro)
sotagliflozin (Inpefa)
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Medication Instructions
Day of Procedure
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