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Ventilator Consent Form
A ventilator consent form is used when an individual is being placed on a ventilator for medical reasons. The form documents the individual's consent to the use of the ventilator and the individual's understanding of the risks and benefits associated with the use of the ventilator.
3 minutes to complete
Eligibility
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.
Questions for Ventilator Consent Form
Questions for 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.
- Yes
- No
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.
- Yes
- No
I understand that the ventilator may cause some discomfort, but that the nurses and doctors will do everything they can to make me comfortable.
- Yes
- No
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.
- Yes
- No
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.
- Yes
- No
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.
- Yes
- No
I hereby consent to receive mechanical ventilation as directed by my healthcare team.
- Yes
- No
Signature
Date
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A ventilator consent form is used when an individual is being placed on a ventilator for medical reasons. The form documents the individual's consent to the use of the ventilator and the individual's understanding of the risks and benefits associated with the use of the ventilator.
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FAQs on Ventilator Consent Form
- No. The Ventilator Consent Form does not give the provider permission to intubate and ventilate you. It does, however, give the provider permission to assess your need for intubation and ventilation.
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