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.
2 minutes to complete
Eligibility
The patients who are scheduled to undergo tracheostomy or their guardians can fill this form.
Questions for Tracheostomy Consent Form
Questions
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.
- Yes
- No
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.
- Yes
- No
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.
- Yes
- No
I hereby give my consent to have a tracheostomy procedure performed on me.
- Yes
- No
Signature
Date
Forms Similar to Tracheostomy Consent Form
- Tracheostomy Consent Form
- Tracheostomy Care Consent Form
- Tracheostomy Tube Change Consent Form
- Tracheostomy Removal Consent Form
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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