Page 4919 - Week 15 - Thursday, 8 December 1994

Woden Valley Hospital

Psychiatry Unit

ELECTRO-CONVULSIVE THERAPY

CONSENT

convulsive therapy has been prescribed by your doctor. Your doctor will discuss with you the number of treatments needed for your condition.

Each treatment is given in the hospital recovery room (near the operating theatre)-You will receive an anaesthetic for the treatment.

I, , consent to anaesthetic and

convulsive therapy which has been explained to me by

Dr. _ I am satisfied with that explanation- I also consent to

any further or alternative measures during the anaesthesia as may be

immediately necessary to preserve health

I understand I may withdraw my consent at any time during the went

Patient

(or legal guardian)

This consent was read by the patient and signed in my presence.

Witness

Dale /

NOTE:

1) If you are receiving went under a Treatment Order under the ACT Mental

Health Act, your consent to Electro-convulsive therapy roust be ratified by the

ACT Court before you receive treatment.

2) You may ask for any medical or legal advice you would like before signing this

consent.

3) The person witnessing the consent should not be the person who will prescribe

or give treatment.

4) No more than 10 (ten) treatments will be given on this consent. Should you

require more than ten treatments, your doctor wit] discuss this with you before

you are asked to consent for further treatment.

5) The medical officer prescribing treatment will countersign the back of this

form.

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