Informed Consent Form - Intensive Care

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INFORMED CONSENT FORM – INTENSIVE CARE
PATIENT’S NAME							UID
Gender				Age				WARD / BED NO.
S. N.	DESCRIPTION
1.	I understand that I / my patient, ……………………………………………………………………………….. (name of patient), has been advised by my doctor, for intensive care in the intensive care unit, as my/my patients’ medical condition has been found to be life-threatening or potentially life-threatening. I have been explained the procedures and treatments that can be done on me / my patient under intensive care and I give my consent to for the same
2.	I understand that under Intensive Care, one or more of the procedures can be carried out on me, as per the assessment of the specialist doctor. The procedures include, but not limited to, Arterial line placement, Baloon pump, BIPAP, Bronchoscopy, CVC, Dialysis, ECMO, Enteral feeding, EVD, ICC, Inotropes, Intravenous Cannula, Intubation, Lumbar Puncture, Swan, Tiger tube, TOE, TPN, Tracheostomy, Transfusion, Urinary Catheter, Vascath and Ventilator application. I understand that each of the procedure under intensive care is linked to certain level of risk to my life and health and I have been explained about the risks. I understand that my consent for intensive care, authorizes the doctors and nurses to carry out one or more of the intensive care functions and I will not be asked for separate consent for these procedures I understand that while staff giving my intensive care will use their professional judgement and skills to their best for my safety, no guarantee can be made for the outcome of intensive care I have been explained about my condition, purpose for putting me under intensive care, expected outcome and consequences of not taking intensive care.
3.	I also understand that during intensive care, my withdrawal of consent can be life-threatening to me/my patient. In case of my decision to withdraw in between from intensive care, the doctors and nurses will take legal regulations into consideration before accepting my decision. I also acknowledge that I have truthfully disclosed, to the best of my knowledge, all medical history and condition, asked to me, by my doctor.
Signature and name of the person giving consent								Date / Time
Relationship with the patient
Signature and name of the witness								Date / Time
Signature and name of the doctor taking consent								Date / Time

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