2 minutes to complete
The patients who are scheduled to undergo tracheostomy or their guardians can fill this form.
Patient Name
Patient Medical ID number
Emergency Contact details
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.
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.
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.
I hereby give my consent to have a tracheostomy procedure performed on me.
Signature
Date
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