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Sedation Consent Forms.

This document provides an informed consent form for sedation during a medical procedure outside the operating room. It outlines: 1) The patient's name, age, and sex. 2) That the purpose of sedation is to make the patient comfortable during the procedure and its effects are temporary. 3) Potential routes of sedative administration and alternatives to sedation. 4) Possible reactions to sedation and need for emergency care. 5) The patient's opportunity to discuss sedation and follow instructions. 6) Requirements to notify doctors of pregnancy, allergies, or other drug use. 7) Limitations on activities after the procedure. The patient agrees to receive

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728 views1 page

Sedation Consent Forms.

This document provides an informed consent form for sedation during a medical procedure outside the operating room. It outlines: 1) The patient's name, age, and sex. 2) That the purpose of sedation is to make the patient comfortable during the procedure and its effects are temporary. 3) Potential routes of sedative administration and alternatives to sedation. 4) Possible reactions to sedation and need for emergency care. 5) The patient's opportunity to discuss sedation and follow instructions. 6) Requirements to notify doctors of pregnancy, allergies, or other drug use. 7) Limitations on activities after the procedure. The patient agrees to receive

Uploaded by

VishwaCr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient Name:

CMIIHOSPI?AL

Age / Sex :

INFORMED CONSENT FOR SEDATION (for procedures performed outside the


operatingroom) ,

I, have been clearly iirformed regarding the sedation to be given to me for performing the.
procedure by Dr tn. language.

7. That the purpose of the sedation is to be comfortable w$te the procedure is being performed
2. I understand that sedation is a drug induced state of reduced awareness and decreased. abitty to
respond. My ability to respond nornrally shall return when the effecb of the sedative wears off.
I may require to be in the hospital for a prolonged period or require admission till the effects of

ffi::lfrf;lf,ur r.auuon will be administered by any one or more of the fouowing routes: oratl
t'- inhamuscular/ intravenous
i
I have been informed that alternatives to sedation include no sedation/anxiolytics to reduce fear
' \}-d--,'
and arxiety
6. A typical reaction to sedatives such as altered mental states, physical reactions, allergic reactions
and other problems may require emergency medical attention and/ or hospitalisation
7. I have had an opportunity to discuss and clarify all doubts regarding sedation with my doctor
and agree to follow all instructions given to me.
8. I understand I must not$ *y doctor if I am pregnant or lactating. I must notify if I am allergic to
hny medication and if tr am taking any psychiitoic.pood altering drugs .
9, I will not be able to operate any machinery or dridh vehicle for hours after the L
procedure 4.:.

Ihereby give my informed coryent to receive sedation for ) - procedure. I have


signed the informed consent knowingly, freely and volu4[arily and agree to be bound by its terms:

Legal Guardian/ Representative


providing the informed consent
(Specrfy relationship)

Details of reason why patient cannot


sign the consent form

*Note: If the patient is a minor or is incapacitated to provide consent. Please specify the name of
the Legal guardian who is providing the informed consent and the relationship of the legal
guardian to the patient.

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