3 minutes to complete
The Ventilator Consent Form must be filled in by a person who has the legal authority to do so. Usually, this will be the patient or a next of kin. If the patient has been declared incompetent by a court, the consent form must be filled by a legal guardian. If the patient is a minor, the consent form must be filled by a parent or legal guardian. If the patient is an adult and has designated a health care surrogate, the health care surrogate will give consent.
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
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