Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pediatric Sedation Consent Form
Your information
Child's Name
Date of Birth
____ / ____ / ________
Child's Weight (kg)
Procedure Requiring Sedation
Sedation Level & Agent
NPO Fasting Status Verified
Allergy & Airway Assessment
| Allergy | Reaction |
|---|---|
Additional details
Sedation Risks Acknowledged
Monitoring Plan Reviewed
Discharge Criteria Explained
Emergency Contact Phone
Relationship to Child
- Parent
- Legal guardian
- Other caregiver
Parent/Guardian Signature
Date
Sedation Provider Signature
Date
Pediatric Sedation Consent Form template from formisoft.com. formisoft.com/intake-templates/pediatric-sedation-consent