IV Sedation Consent Form

Patient Information:

• Full Name: _______________________________
• Date of Birth: _____________________________
• Address: __________________________________
• Phone Number: ____________________________
• Email Address: ____________________________

Procedure Information:

I, _____________________________ [patient's name], hereby consent to undergo intravenous (IV) sedation for the following procedure:

• Procedure Name: ___________________________
• Date of Procedure: _________________________
• Expected Duration of Procedure: _____________

Description of IV Sedation:

IV sedation involves the administration of sedative medications through a vein to induce a state of relaxation, drowsiness, and decreased awareness during the procedure. It is intended to alleviate anxiety and discomfort while allowing the patient to remain responsive to verbal commands.

Risks and Benefits:

I understand that IV sedation carries certain risks, including but not limited to:

• Allergic reactions to medications
• Respiratory depression or airway obstruction
• Cardiovascular complications
• Nausea or vomiting
• Headache or dizziness
• Temporary memory loss or confusion

I also understand that the benefits of IV sedation include:

• Reduced anxiety and fear
• Increased comfort during the procedure
• Improved cooperation and compliance

Alternative Options:

I acknowledge that alternative forms of sedation or anesthesia, as well as performing the procedure without sedation, have been discussed with me. I understand that I have the right to refuse IV sedation and choose an alternative option if desired.

Informed Consent:

I have had the opportunity to discuss the risks, benefits, and alternatives to IV sedation with my healthcare provider. I have had all my questions answered to my satisfaction, and I understand the information provided.

By signing below, I voluntarily consent to undergo IV sedation for the specified procedure, understanding the associated risks and benefits.

Patient Signature: ____________________________
(Date: ________________)

Witness Signature: ___________________________
(Date: ________________)

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