Sedation – IV Conscious Sedation Consent Form

I understand that conscious sedation involves the administration of medication to relax me and alleviate pain or anxiety during the procedure. I have been informed of the following:

  1. Purpose of Sedation: The conscious sedation is being administered to improve my comfort and cooperation during the procedure.
  2. Benefits: I understand that conscious sedation may reduce discomfort, pain, and anxiety during the procedure.
  3. Risks: I am aware that, like all medical interventions, conscious sedation carries certain risks, including but not limited to:
    • a. Allergic reactions to the sedation medications.
    • b. Breathing difficulties.
    • c. Nausea or vomiting.
    • d. Low blood pressure.
    • e. Over-sedation, leading to drowsiness or reduced consciousness.
    • f. Rare complications, which will be discussed with me by the healthcare team.
  4. Alternative Options: I understand that alternatives to conscious sedation, including performing the procedure without sedation or using different methods, have been discussed with me.
  5. Procedure Description: I have been informed about the nature of the procedure, its purpose, the potential benefits, and the risks associated with it. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.
  6. Anesthesia Provider: I acknowledge that the anesthesia provider, [Name of Anesthesia Provider], will be responsible for administering the sedation and monitoring my condition during the procedure.
  7. Voluntary Consent: I consent to conscious sedation voluntarily, and I understand that I have the right to withdraw my consent at any time.
  8. Patient Acknowledgment: I understand that I may experience temporary memory loss or altered perception as a result of the sedation, and I agree not to operate heavy machinery or make important decisions for the remainder of the day following the procedure.
  9. Emergency Procedures: I acknowledge that in the event of an unforeseen emergency during the procedure, the healthcare team may need to take actions in my best interest, including changing the type of anesthesia, sedation, or administering life-saving measures.

    Patient Information:

    Witness:


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