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ECT Discharge instructions No driving on the day of treatment. Resume meals and medications as prescribed. If headache or muscle aches occur, you may take over the counter analgesics such as Tylenol, Motrin or Aspirin. If you develop a fever or other side effects, contact either your outpatient clinic, or the ECT Nurse at 761-8507. Your next ECT appointment will be Please come to ward 102 by 2 pm on the day prior to your scheduled treatment. Other instructions. 621 B-prdc ECT LIPC (2/00) Side 1 State of New York, Office of Mental Health PILGRIM PSYCHIATRIC CENTER Patient's Name (Last First, M.I.) "C"/Id. No. INFORMED CONSENT FOR ECT (PERIODIC REVIEW) Sex: Date of Birth: ECT Start Date: Bldg/Ward No: 1,_____ have reviewed the (Patient's Name) Electroconvulsive treatment for the past three (3) months with my physician and treatment team. I understand that further ECT treatments are recommended to me, and have also been explained to me by Dr. who has answered any questions I have had. I agree to continue these treatments. The procedure was discussed with family / significant other [ ] yes [ ] No (Progress Note wrltten__) Patient's Signature: Psychiatrist Signature & Title (Print Name) Date have reviewed the (Patient's Name) Electroconvulsive treatment for the past three (3) months with my physician and treatment team. I understand that further ECT treatments are recommended to me, and have also been explained to me by Dr. who has answered any questions I have had. I agree to continue these treatments. The procedure was discussed with family / significant other: [ ] Yes [ ] No (Progress Note written___) Patient's Signature: Psychiatrist Signature & Title (Print Name) Date 621 B-prdc ECT LIPC (2/00) Side 2 56 State of New York, Office of Mental Health 57 PILGRIM PSYCHIATRIC CENTER Patient's Name (Last, First, M.I.) "C"/ld. No. INFORMED CONSENT FOR ECT (PERIODIC REVIEW) Sex: Date of Birth: ECT Start Date: I Bldg/Ward No: have reviewed the (Patient's Name) Electroconvulsive treatment for the past three (3) months with my physician and treatment team. I understand that further ECT treatments are recommended to me, and have also been explained to me by Dr. who has answered any questions I have had. I agree to continue these treatments. The procedure was discussed with family / significant other: [ ] Yes [ ] No (Progress Note written_____) Patient's Signature: Psychiatrist Signature & Title (Print Name) Date |
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