Ventilator Consent Form

Name of the Patient

Patient Medical ID number

I understand that the purpose of the ventilator is to help me breathe, the ventilator will be placed in my mouth and/or nose, and that it will be connected to my lungs.

I understand that the ventilator will be turned on and off as needed, and that I may be able to talk while it is on.

I understand that the ventilator may cause some discomfort, but that the nurses and doctors will do everything they can to make me comfortable.

I understand that I will be monitored closely while on the ventilator, and that the nurses and doctors will make sure that I am getting the air that I need.

I understand that I will be closely monitored by my healthcare team while I am on mechanical ventilation and that they will make every effort to minimize any discomfort or side effects that I may experience.

I understand that the ventilator may cause some discomfort, such as a sore throat, and that I may have to stay in the hospital for a while.

I hereby consent to receive mechanical ventilation as directed by my healthcare team.

Signature

Date