Anesthesia Consent Form

CONSENT FOR Intravenous SEDATION OR GENERAL ANESTHESIA

Please initial each paragraph after reading.  If you have any questions about your proposed treatment, please ask your doctor BEFORE initialing or signing this form. You have the right to be informed about this so that you can decide whether to have it or not after knowing the risks and benefits.  These common procedures are considered quite safe.  Nevertheless, all procedures have some risks.  They include the following and others:

I give consent to allow my doctor to administer intravenous sedation or general anesthesia, and to all invasive measures necessary to monitor and care for me during my anesthetic.

_____ that go along with Discomfort, swelling or bruising where the drugs are placed into a vein.

Vein irritation, called phlebitis, where the drugs are placed into a vein.  Sometimes this may grow to a level of discomfort or disability where it may be difficult to move your arm or hand.  Sometimes medication or other treatment may be required.

Nerves travel next to the blood vessels where the drugs are placed into a vein.  If the needle hits a nerve or if drugs or fluid leaks out of the vessel around a nerve, you may have numbness or pain in the nerve where it runs along the arm.  Usually the numbness or pain goes away, but in some cases, it may be permanent.

Allergic reactions (previously unknown) to any of the medications used.

Nausea and vomiting, although not common, are possible unfortunate side effects.  Bed rest, and sometimes medications, may be required for relief.

_____ Intravenous sedation and general anesthesia are serious medical procedures and, whether given in a hospital or office, carry the risk of brain damage, stroke, heart attack or death. 

______ If any unforeseen condition should arise during surgery that may call for additional or different procedures from those planned, I authorize my doctor to use medical judgment to provide the appropriate care.

_____ I recognize that the office policy of this facility is to not electively treat patients with advanced directive, Do Not Resuscitate (DNR) orders.  If I have such an order, I waive the order, and agree to be resuscitated for this anesthesia / surgical procedure

YOUR OBLIGATIONS:

_ Because anesthetic or sedative medications (including oral premedication) causes drowsiness that lasts for some time, you MUST be accompanied by a responsible adult to drive you to and from surgery, and stay with you for several hours until you are recovered sufficiently to care for yourself.  Sometimes the effects of the drugs do not wear off for 24 hours. During recovery time (normally 24 hours), you should not drive, operate complicated machinery or devices or make important decisions such as signing documents, etc.  On some occasions, especially in older people and with longer cases, it takes longer than expected, weeks to months, to feel fully recover from the anesthetic effects.

You must have a completely empty stomach.  It is vital that you have NOTHING TO EAT OR DRINK for eight (8) hours prior to your treatment.  TO DO OTHERWISE MAY BE LIFE-THREATENING.

_____ Unless instructed otherwise, it is important that you take any regular medications (high blood pressure, antibiotics, etc.) or any medicines given to you by your surgeon using only a small sip of water.