<p> DUKE HEART CENTER CARDIOVERSION/TEE INTAKE FORM</p><p>ALL PATIENTS FOR DCCV, TEE/DCCV MUST BE ANTICOAGULATED</p><p>Patient name History number Location Duke Hospital Patient home phone Requesting Attending PERSON SCHEDULING Name: ______Phone / Pager: ______PROCEDURE DEVICE ?  None  Pacer  ICD  DCCV through device Procedure DCCV_____ DCCV/TEE_____ Date:______Time:______Diagnosis  A-Fib  A-Flutter  Other ______</p><p>REQUIRED FOR PROCEDURE* FAX LABS, H&P, AND FORM TO 919-684-1747 *important to ensure safe procedure</p><p>Anticoagulated with:  Coumadin  Heparin  Lovenox  Pradaxa  Xarelto warfarin enoxaparin dabigatran rivaroxaban #1 Date ______INR______PTT_____ CURRENT ( within 48 hours) INR #2 Date ______INR______PTT_____ PLUS last 3 or past 3 weeks if on warfarin #3 Date ______INR______PTT_____ #4 Date ______INR______PTT_____ WITHIN 30 DAYS OF Cardioversion needs: Date ______BMP__ __ H&P____ PROCEDURE TEE needs: Date ______BMP__ __CBC_____ H&P____ To Schedule Procedure: Call (919) 684-5295 (press 1) Clinical Questions: Call treatment room nurse at (919) 681-7241</p><p>(Tear here and give to patient)</p><p>PATIENT INSTRUCTIONS 1. Nothing to eat or drink after midnight the night before the procedure 2. If instructed to take medications, take with water only 3. Must have a driver with you. 4. Nothing to eat or drink for 2 hours after TEE procedure 5. Report to Duke Hospital, 7th floor - Cardiac Catheterization Waiting Room 6. Questions? Call Treatment Room Nurse (919) 681-7241 7. Call (919) 684-5295 (when prompted, press 1) to change appointment </p><p>BKD/SR 1/2010</p>