I understand that the act of anesthtics has benefits to relief and protection from pain and discomfort during
the operation / procedure and anesthesia services are useful and needed so that the operation / procedure can be performed.
I understand that the type and technique of anesthesia to be used is determined by many factors patient's physical condition, the type
of procedure or operation, the surgeon / anesthesiologist’s preference, as well as my own desire. The benefits, advantages and disadvantages
of each anesthetic technique has been explained to me. I also have been explained that sometimes an anesthesia technique which involves the use
of local anesthetics may not succeed completely and therefore another technique may have to be used including general anesthesia.
I understand that any type of anesthesia involves risk, including nausea, sore throat, jaw pain, and injury to teeth, eyes or skin.
More serious risks include drug reactions; nerve, blood vessel or lung injury; paralysis or even cardiac arrest. In addition,
I understand that headache, backache and persistent numbness can occur after spinal or epidural anesthesia.
Anesthetic plan, types and alternatives of anesthesia, benefits and risk have been explained to me and I agree with the type of anesthesia
checked below will be used:
Name :
Age :
File No. :
Attending Staff :
General Anesthesia
Spinal or Epidural Anesthesia
Sedation
Brachial Plexus Nerve block
Peripheral Nerve Block
Monitored Anesthesia Care
Other
I have had the opportunity to ask questions about the above anesthetic technique and I am satisfied with the information I have received.
IF I do not fully understand spoken English, I have had opportunity of utilizing an interpreter.
I have therefore placed my signature below to enable the anesthesiologist and his/her associates to perform the anesthesia.
