2 page due 10/5

SPECIAL PROCEDURE CONSENT FORM I have read, or have had read to me, and understand the following authorization for ______________________________________________________________________ ______________________________________________________________________ I authorize Dr. __________________________________ to perform the above described procedure or treatment. I have discussed my medical condition, the proposed treatment or procedure, alternatives to this treatment and the risks associated with them with my physician. I have been informed that in the performance of any invasive procedure, there is the potential for damage to my organs, nerves, and blood vessels, allergic reaction, blood clots, inadvertent puncture, laceration, infection, consequent hemorrhage, and very rarely death. I fully understand that it may be necessary to proceed with additional procedures, or possibly surgery, to repair the injury or control and treat the complication. I specifically request my physician to proceed with whatever is deemed medically necessary and request that I be given a full explanation after the effects of sedation have subsided. I agree to the administration of blood or blood products if they are required. (Potential risks of blood transfusions include the risk of hepatitis, AIDS, or other infections or reactions). I agree to the administration of contrast (IV dye) if required. (Potential risk of contrast reaction). I agree that any tissue or parts surgically removed may be disposed of in accordance with the hospital’s accustomed practice. I agree that my physician may permit photographs or video tapes of my procedure or treatment, employing appropriate privacy draping of my person, to record the procedure for the express purpose of medical education or to provide a record to be filed with strict confidence with my medical records. I have been informed that other practitioners may be performing important aspects of the procedure, administering anesthesia or implanting devices that are within their scope of practice. I consent to the observation of my procedure or treatment by individuals for the purposes of medical education and to the presence of a medical representative in the operating/procedure room. I understand medical representative to mean non-medical technician of companies which have furnished operating room/procedural equipment and supplies. During this procedure I may receive MODERATE SEDATION which is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are usually required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. The patient is usually very sedated, but may still be able to hear and respond to their medical providers and remembers some

or all of their experience. Side effects and complications of moderate sedation are relatively uncommon but can occur. While it is impossible to advise you of every conceivable complication, some possible examples are; • Progression to a deeper level of sedation.

Soreness of the throat and hoarseness are very common occurrences • Aspiration (inhaling stomach contents into the lungs), asthma attacks,and pneumonia. • Nerve injuries and possible weakness or paralysis. • Allergic-type reactions leading to cardiac arrest and death. • Nodules, polyps, or other damage to the vocal cords or windpipe. • Sometimes dreams during anesthesia are confused with recall of real events. • Medical complications involving damage to the eyes, heart, lungs, and circulatory system such as corneal abrasions, blindness, stroke, blood clots, abnormal heart rhythms, phlebitis, collapsed lung, and heart attack. • Possible traumatic injury to the jaw which may include dislocation, arthritis, temporomandibular joint (TMJ) disorder or chronic pain. Teeth and dental prosthetics may become loose, broken, or dislodged, especially if loose or in poor repair regardless of the care provided by the provider. By signing this consent you are acknowledging that your providers and Martin Health System will not be liable for any dental damage or repairs. I have had the opportunity to have my questions answered to my satisfaction. I authorize my physicians and Martin Memorial to disclose health information related to this treatment or procedure to any friend or family member who has accompanied me or who is waiting for me, even if I am competent or available, with the exception of the following: ______________________________________________________________________ _____________________________________________ _________________ Patient/Authorized Surrogate or Proxy Signature Date/time _____________________________________________ _________________ Witness Signature Date/time I certify that I have explained the nature, purpose, benefits, risks, complications, and alternatives to the proposed procedure as well as the risks, benefits and alternatives of moderate sedation to the patient or the patient's legal representative. I have answered all questions fully, and I believe that the patient / legal representative fully understand what I have explained. I further certify that I have validated the procedure/site and side and that the correct procedure site has been marked, if indicated, prior to the procedure being performed. The patient has been evaluated and is a candidate for moderate sedation. _____________________________________________ _________________ Practitioner Signature Date/time □ “Language Line” SM used to interpret consent form for patient.

PATIENT LABEL

MARTIN MEMORIAL HEALTH SYSTEMS STUART, FLORIDA

SPECIAL PROCEDURE CONSENT RM058 4/01, 7/07, 10/08, 1/10, 8/11, 5/13

REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK MANAGEMENT.