Conscious Sedation Consent Form

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The conscious sedation consent form should be used to ensure that patients have a complete understanding of the sedation that will be provided along with their treatment. The document is also used to provide consent for said sedation. Each statement should be reviewed by the patient and should be questioned if necessary. Once the patient has a total comprehension of the information relayed in each paragraph, and all inquiries have been satisfied, they may provide their initials where applicable.

Conscious Sedation Guide – Use as an informational supplement.

Common of Drugs Used

Opioids

  • Fentanyl (Sublimaze)
  • Hydromorphone (Dilaudid)
  • Meperidine (Demerol)
  • Morphine
  • Oral Transmucosal Fentanyl Citrate (OTFC)

Benzodiazepines

  • Midazolam (Versed)
  • Diazepam (Valium)
  • Lorazepam (Ativan)

How to Write

Step 1 – Download in Adobe PDF (.pdf).

 

Step 2 – Initial here if you the reason for the employment of conscious sedation and that it is not necessary to provide the medical care.

Step 3 – This paragraph explains the effects of conscious sedation. Initial when ready.

Step 4 – Initial here to acknowledge that you are aware of how you will be sedated, how long before the appointment, and the duration of the sedation.

Step 5 – When made aware of the alternatives, initial where applicable.

Step 6 – There are of course risks and limitations involved. Review the statements and initial next to each when a full understanding has been reached.

Step 7 – This paragraph, once initialed, allows the medical staff to make alterations in the treatment when required.

Step 8 – Initial here to signify that you have had all questions answered and that you will follow all treatments and instructions given by your healthcare professional (s).

Step 9 – Initial if you understand that you must let your doctor know if you are pregnant or lactating. Furthermore, you must notify him if any of the other conditions/states listed in this paragraph are applicable.

Step 10 – Initial here to ensure that you will not drive or operate heavy machinery after taking the sedative.

Step 11 – The final initial field is used to consent to the sedation. Below it, provide the date and, once the form has been printed off, your signature and that of a witness.

Step 12 – Sign here as well to consent to the administration of local anesthetic.

Step 13 – Sign the final page to show proof that you have been notified not to do the activities listed therein.