AUTHORIZATION TO TREAT

MECHANICAL VENTILATOR
I, ____________________________________, (name of client) understand and acknowledge
that there is a degree of risk associated with the MECHANICAL VENTILATOR that the physician
has ordered for my use:
Risks include, but are not limited to:
Failure to properly provide adeuate ventilation
!echanical failure leading to cessation of ventilatory support and"or death
Note: Client and/or caregivers shold !e trained in e"ergenc# cardio$l"onar#
resscitation and the $ro$er se o% a "anal resscitation device&
I understand this home therapy must be used in accordance with the physician#s prescription,
manufacturer#s recommendations and directions provided by __________________ and have
been instructed in same$
I hereby authori%e __________________, referenced below, to initiate the prescribed treatment
and to instruct regarding the proper use of the device$

&lient 'ignature (ate

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