Healthcare Sedated Rads Consent Form

Healthcare Sedated Rads Consent Form

Patient Information

Patient Name:   Medical Record #:

Insurance Information

Medical History

Procedure and Sedation Details

Procedure / Exam:   Scheduled Date:   Scheduled Time:

I authorize administration of sedation and/or analgesia as required for the above radiology procedure by qualified personnel (anesthesiologist, CRNA, or sedation-certified physician/provider). Sedation may include intravenous agents, inhaled agents, and other medications as judged necessary to provide comfort and safety.

Risks, Benefits and Alternatives

The nature and purpose of sedation have been explained to me. I understand the benefits include decreased anxiety and discomfort and improved ability to complete the diagnostic or therapeutic procedure. I understand the risks, which may include but are not limited to:

• Respiratory depression or airway obstruction requiring intervention, including oxygen, airway adjuncts, assisted ventilation, or intubation.
• Aspiration of stomach contents with possible pneumonia or other complications.
• Allergic or idiosyncratic reactions to medications or contrast agents, which may be severe.
• Cardiovascular complications including hypotension, arrhythmia, or cardiac arrest.
• Prolonged sedation or delayed recovery of consciousness.
• Permanent neurological injury or death (rare).

Alternatives to sedation include undergoing the procedure with no sedation, procedural postponement, or referral for general anesthesia in an operating room setting. I have had the opportunity to ask questions and have them answered to my satisfaction.

Pre-procedure Instructions and Considerations

NPO (nothing by mouth) since:   If diabetic or taking critical medications, further instructions were discussed.

I have been instructed which medications to take or hold prior to sedation (e.g., anticoagulants, diabetic medications). I confirm I have informed staff of all medications and supplements I take.

Specific Items — Check as Applicable

I consent to IV access for administration of medications and fluids.

I consent to continuous monitoring of heart rate, oxygen saturation, blood pressure, and respiratory status during and after the procedure.

I consent to administration of contrast agents if required for the radiologic procedure and understand contrast carries risks including allergic reaction.

Pregnancy and Childbearing Potential

If the patient is of childbearing potential, a pregnancy test is required prior to sedation. Pregnancy test performed:    Yes    No   Date of test:

HIPAA / Privacy Notice Acknowledgment

I acknowledge that I have been offered the facility's Notice of Privacy Practices describing how my health information may be used and disclosed for treatment, payment and health care operations. I understand that my protected health information may be disclosed to the sedation and radiology team as needed for my care.

I acknowledge receipt of the privacy notice.

Authorization and Consent

By signing below, I authorize the administration of sedation, analgesia, and related medications as described above and agree to such monitoring and interventions as deemed necessary by the sedation team. I understand the risks, benefits, and alternatives and give informed consent for the procedure and sedation. I authorize disclosure of relevant medical information to my insurer for billing and to other health care providers for continuity of care.

Staff Obtaining Consent

Sign Now