PARC Surgical - Anesthesia Disclosure and Consent

1
Patient Name* This field is required.
First Name
Last Name
2
Patient Birth Date* This field is required.
Month
Day
Year
3
DISCLOSURE AND CONSENT - ANESTHESIA and/or PERIOPERATIVE PAIN MANAGEMENT (ANALGESIA)

You have the right as a patient to be informed about your condition and the recommended anesthesia to be used so that you may make the decision whether or not to receive the anesthesia after being informed of the risks, benefits, and alternatives. This disclosure is an effort to make you better informed so you may give or withhold your consent to the anesthesia/analgesia.

Information about General Anesthesia: A member of the anesthesia care team will visit you before your treatment/procedure to discuss the type of anesthesia you may need and to give you more information about anesthesia. It may become necessary to alter your anesthesia care plan after the discussion. Devices may be applied to your body and placed in your veins and arteries to monitor you during your anesthesia. All forms of anesthesia involve some risk. Minor (not life threatening) risks include nausea, vomiting, and pain where an injection is given. Although rare, severe complications include injury to blood vessels, drug reactions, bleeding, blood clots, loss of sensation or limb function, infection, paralysis, stroke, brain damage, heart attack, and death. General anesthesia involves drugs being injected into the bloodstream or breathed into the lungs. A tube or other device may be inserted into your airway to help you breathe. The anticipated benefit is that you will be totally unconscious and you will not feel pain during the procedure. Additional risks include injury to the teeth, throat, eyes or lungs. In less than 1 case in 1000, patients may be aware of the occurrences during their surgery.
4
I voluntarily request that anesthesia and/or perioperative pain management care (analgesia) as indicated below be administered to me (the patient). I understand it will be administered by an anesthesia provider and/or the operating practitioner, and such other health care providers as necessary. Perioperative means the period shortly before, during and shortly after the procedure.
5
I understand that anesthesia involves additional risks and hazards, but I request the use of anesthestics/analgesia for the relief and protection from pain during the planned and additional procedures. I realize the type of anesthesia/analgesia may have to be changed, possibly without explanation to me.
6
I understand that serious, but rare, complications can occur with all anesthetic/analgesic methods. Some of these risks are breathing and heart problems, drug reactions, nerve damage, cardiac arrest, brain damage, paralysis, or death.
7
General Anesthesia Risks* This field is required.injury to vocal cords, teeth, lips, eyes; awareness during the procedure; memory dysfunction/memory loss; permanent organ damage, brain damage
8
Regional Block Anesthesia/Analgesia Risks* This field is required.nerve damage; persistent pain, bleeding/hematoma; infection; medical necessity to convert to general anesthesia; brain damage
9
Spinal Anesthesia/Analgesia Risks* This field is required.nerve damage; persistent back pain; headache; infection; bleeding/epidural hematoma; chronic pain; medial necessity to convert to general anesthesia; brain damage
10
Epidural (Thoracic, Lumbar, Caudal) Anesthesia/Analgesia Risks* This field is required.nerve damage; persistent back pain; headache; infection; bleeding/epidural hematoma; chronic pain; medical necessity to convert to general anesthesia; brain damage
11
Monitored Anesthesia Care (MAC) or Sedation/Analgesia Risks* This field is required.memory dysfunction/memory loss; medical necessity to covert to general anesthesia; permanent organ damage; brain damage
12
Deep Sedation Risks* This field is required.memory dysfunction/memory loss; medical necessity to covert to general anesthesia; permanent organ damage; brain damage
13
Moderate Sedation Risks* This field is required.memory dysfunction/memory loss; medical necessity to covert to general anesthesia; permanent organ damage; brain damage
14
Prenatal/Early Childhood Anesthesia (36 months or younger) Risks* This field is required.potential long-term negative effects on memory, behavior, and learning with prolonged or repeated exposure to general anesthesia/moderate sedation/deep sedation during pregnancy and in early childhood
15
I understand that no promises have been made to me as to the result of anesthesia/analgesia methods.

I have been given an opportunity to ask questions about my anesthesia/analgesia methods, the procedure to be used, the risks and hazards involved, and alternative forms of anesthesia/analgesia. I believe that I have sufficient information to give this informed consent.

This form has been fully explained to me, I have read it or have had it read to me, the blank spaces have been filled in, and I understand its contents.
16
Signature of Patient/Parent/Other Legally Responsible Person* This field is required.
17
Name of Parent or Legally Responsible Person
First Name
Last Name
18
Relationship to Patient:
19
Date and Time* This field is required.
Date
Month
Day
Year
1
1
2
3
4
5
6
7
8
9
10
11
12
Hour
25
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
AM
PM
20
----------------------- for office use only -------------------------

WITNESS: ____________________________________

WITNESS NAME: _______________________________

PHYSICIAN: ___________________________________

DATE: ___________________

TIME: ____________________
Should be Empty: