Nasogastric (NG) Tube Insertion Consent Form

Consent for Nasogastric (NG) Feeding Tube Placement:

INTRODUCTION:
Your physician has requested that you undergo a nasogastric (NG) feeding tube placement to allow feeding directly into your stomach or intestines.

We are asking you to read and sign this form so that we can be sure you understand the procedure and potential benefits, along with the associated potential risks, complications, alternatives, the likelihood of achieving the goals, and the recuperative process.

Please ask questions about anything on this form that you do not understand.

PROCEDURE:
Before the procedure, a small tube will be inserted through your nostrils and down into your stomach. The position of the tube may then be confirmed by the x-ray.

RISKS:
Risks associated with the procedure include, but are not limited to, pain or discomfort, nosebleeds, sinus infection, misplacement, trauma, stomach lining irritation, entanglement, tube breakage, allergic reaction and there may be other
unpredictable risks including death.

AGREEMENT:
The information on this form was explained to me by a Physician. I understand the
information and I have had the opportunity to ask any other questions I might have about the procedure, the reasons it is being performed, the associated risks, and the alternatives to the procedure.

I agree to undergo the procedure to be performed by an authorized member of staff and other appropriate hospital personnel, and accept the risks.

I also agree that staff members may participate in significant tasks that are part of the procedure.

In addition, I agree to have any other appropriate personnel present for the procedure.

I assign to Halimatu Musa Hospital all rights to any tissues, organs, cells, body parts, and/or body fluids that may be removed during this procedure and I authorize the Hospital to use or dispose of such specimens according to its standard practices.