Section 66

Form 26

Electroconvulsive Therapy (ECT) informed consent

Full name of patient: Also known as: Date of Birth: / /	Sex: ☐ Male ☐ Female ☐ Non-binary ☐ Not specified HRN: Name of Approved Treatment Facility or Agency:
Informed consent of patient The doctor below has explained my diagnosis for which Electroconvulsive therapy (ECT) is proposed.
Full name of doctor performing ECT
☐ The doctor has also explained ECT, how it is done and how it will benefit my condition. ☐ I understand that ECT is given under a general anaesthetic and with a muscle relaxant. The doctor has explained their purpose and how they are given. ☐ The doctor has explained the risks and possible side effects of ECT, the general anaesthetic and the muscle relaxant. ☐ The doctor has explained other possible treatment options for my condition, including the advantages, disadvantages and risks of each option and the risks if I do not have treatment. ☐ I have been given the statement of rights Electroconvulsive treatment and the information has been explained to me. ☐ I have had an opportunity to ask questions about ECT and other treatment options and my questions have been answered. ☐ I understand the information I have been given. ☐ I have had an opportunity to get other advice or help to make the decision. ☐ I understand that the results of ECT cannot be guaranteed. If changes to my ECT treatment are needed that affect my consent, these will be discussed with me and a doctor will seek my informed consent to the changes. ☐ I have had enough time to make my decision. ☐ I understand that I can withdraw my consent to ECT at any time, even after the course of ECT has started.
As such, I consent to a course of ECT up to 12 treatments, which may take up to weeks to complete (up to a maximum of 26 weeks). I am 18 years or older: Yes ☐ No ☐
Diagnosis:
Signature of patient: Date: / /	Signature of witness: Date: / /

Form Requirements

☐ Placed on clinical file