Tracheostomy Consent Form

The Tracheostomy Consent Form is a legal document that protects the medical practitioner from any legal liability in case the patient suffers any complications during or after the surgical procedure. The form also requires the patient’s signature, which gives the doctor the permission to carry out the tracheostomy.

Time to complete

2 minutes

Eligibility

The patients who are scheduled to undergo tracheostomy or their guardians can fill this form.

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Questions for Tracheostomy Consent Form

1.

Patient Name

The answer should be a text input.
2.

Patient Medical ID number

The answer should be a single choice:
    3.

    Emergency Contact details

    The answer should be a text input.
    4.

    I understand that the purpose of this procedure is to provide me with a way to breathe more easily and that it may be temporary or permanent.

    The answer should be a single choice:
    1. Yes
    2. No
    5.

    I understand that these risks will be explained to me in more detail by my doctor prior to the procedure. I also understand that there are alternative treatments available to me and that I may choose to not have this procedure performed.

    The answer should be a single choice:
    1. Yes
    2. No
    6.

    I understand that this procedure involves making an incision in my neck and creating an opening in my trachea (windpipe) through which I will breathe. I understand that there are risks associated with this procedure, including but not limited to: bleeding, infection, scarring, and damage to the nerves in my neck.

    The answer should be a single choice:
    1. Yes
    2. No
    7.

    I hereby give my consent to have a tracheostomy procedure performed on me.

    The answer should be a single choice:
    1. Yes
    2. No
    8.

    Signature

    The answer should be a signature.
    9.

    Date

    The answer should be a date input.

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    Here are some FAQs and additional information
    on
    Tracheostomy Consent Form

    What is a tracheostomy?

    A tracheostomy is a medical procedure that involves making a cut in the trachea (windpipe) in order to insert a tube into the airway. This tube is then used to help a person breathe.

    Who needs a tracheostomy?

    A tracheostomy may be recommended for people who have difficulty breathing due to a blockage in the airway or who need assistance with ventilation (breathing).

    What are the risks of a tracheostomy?

    There are several risks associated with a tracheostomy, including bleeding, infection, and damage to the surrounding tissue. In rare cases, a tracheostomy may also lead to death.

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