Form DHCS1800 "Electroconvulsive Treatment (Ect), Informed Consent Form" - California

What Is Form DHCS1800?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2019;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS1800 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS1800 "Electroconvulsive Treatment (Ect), Informed Consent Form" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
ELECTROCONVULSIVE TREATMENT (ECT), INFORMED CONSENT FORM
DO NOT SIGN THIS FORM UNTIL YOU HAVE ALL THE INFORMATION YOU DESIRE
CONCERNING ELECTROCONVULSIVE TREATMENT (ECT).
The nature and seriousness of my mental Condition, for which ECT is being recommended, is:
RECOMMENDATION: I understand that ECT involves passage of an electrical stimulus across
my brain for a few seconds, sufficient to induce a seizure. In my case the treatments will
probably be given
_ times per week for
weeks, not to exceed a total of
treatments and not to exceed 30 days from the first treatment. Additional treatments
cannot be given without my written consent.
Reasonable alternative treatments (such as psychotherapy and/or medication) have been
considered and are not presently recommended by my doctor because
IMPROVEMENT: I understand that ECT may end or reduce depression, agitation and
disturbing thoughts. In my case there may be permanent improvement, no improvement, or
the improvement may last only a few months. Without this treatment my condition may
improve, worsen or continue with little or no change.
SIDE EFFECTS AND RISKS: I understand there is a division of opinion as to the effectiveness
of this treatment as well as uncertainty as to how this procedure works.
I also understand this treatment may have brief side effects: headaches, muscle soreness
and confusion.
There may be some memory loss which could last less than an hour or there may be a
permanent spotty memory loss. Memory loss and confusion may be lessened by the use of
unilateral (one-sided) electrical brain stimulation rather than bilateral (two-sided) stimulation.
Anesthesia and muscle relaxants will be used during these treatments to prevent accidental
injury. Oxygen will be administered to minimize the small risk of heart, lung, brain malfunction
or death as a result of the anesthesia or treatment procedures.
My physician states I have the following medical condition(s) which increase the risk in my
case, as follows:
I HAVE THE RIGHT TO ACCEPT OR REFUSE THIS TREATMENT. IF I CONSENT, I HAVE
THE RIGHT TO REVOKE MY CONSENT FOR ANY REASON AT ANY TIME PRIOR TO OR
BETWEEN TREATMENTS.
Dr.
has explained the above information to my satisfaction. At
least 24 hours have elapsed since the above information was explained to me. I have carefully
read this form or had it read to me and understand it and the information given to me.
I HEREBY CONSENT TO ECT
Signature
Date and Time
Witness Signature
DHCS 1800 (05/19)
State of California
Department of Health Care Services
Health and Human Services Agency
ELECTROCONVULSIVE TREATMENT (ECT), INFORMED CONSENT FORM
DO NOT SIGN THIS FORM UNTIL YOU HAVE ALL THE INFORMATION YOU DESIRE
CONCERNING ELECTROCONVULSIVE TREATMENT (ECT).
The nature and seriousness of my mental Condition, for which ECT is being recommended, is:
RECOMMENDATION: I understand that ECT involves passage of an electrical stimulus across
my brain for a few seconds, sufficient to induce a seizure. In my case the treatments will
probably be given
_ times per week for
weeks, not to exceed a total of
treatments and not to exceed 30 days from the first treatment. Additional treatments
cannot be given without my written consent.
Reasonable alternative treatments (such as psychotherapy and/or medication) have been
considered and are not presently recommended by my doctor because
IMPROVEMENT: I understand that ECT may end or reduce depression, agitation and
disturbing thoughts. In my case there may be permanent improvement, no improvement, or
the improvement may last only a few months. Without this treatment my condition may
improve, worsen or continue with little or no change.
SIDE EFFECTS AND RISKS: I understand there is a division of opinion as to the effectiveness
of this treatment as well as uncertainty as to how this procedure works.
I also understand this treatment may have brief side effects: headaches, muscle soreness
and confusion.
There may be some memory loss which could last less than an hour or there may be a
permanent spotty memory loss. Memory loss and confusion may be lessened by the use of
unilateral (one-sided) electrical brain stimulation rather than bilateral (two-sided) stimulation.
Anesthesia and muscle relaxants will be used during these treatments to prevent accidental
injury. Oxygen will be administered to minimize the small risk of heart, lung, brain malfunction
or death as a result of the anesthesia or treatment procedures.
My physician states I have the following medical condition(s) which increase the risk in my
case, as follows:
I HAVE THE RIGHT TO ACCEPT OR REFUSE THIS TREATMENT. IF I CONSENT, I HAVE
THE RIGHT TO REVOKE MY CONSENT FOR ANY REASON AT ANY TIME PRIOR TO OR
BETWEEN TREATMENTS.
Dr.
has explained the above information to my satisfaction. At
least 24 hours have elapsed since the above information was explained to me. I have carefully
read this form or had it read to me and understand it and the information given to me.
I HEREBY CONSENT TO ECT
Signature
Date and Time
Witness Signature
DHCS 1800 (05/19)