The hospital may communicate with you via text. If you do not have a mobile phone, please provide the number of a trusted family member / friend
The hospital may communication with you via email. If you do not have an email address, please provide an email of a close family member / friend and verify as instructed
In consenting to this operation / procedure, I understand that an anaesthetic is required and also understand that adverse effects of general anaesthesia may include nausea, vomiting, sore throat, fatigue, altered mental state and brusing at intravenous sites.
Uncommon adverse effects such as dental trauma and spinal headaches (following spinal anaesthesia) are possible. Rare adverse effects, which are unpredictable, may occur such as anaphylaxis, awareness, nerve damage or death.
Adverse effects related to pre-existing diseases may occur during emergency surgery and may have fatal results. Blood transfusion, if required, may produce adverse effects and rarely serious complications.
I understand that I will have the opportunity to discuss this information / risks with my anaesthetist.
I, patient / partent / guardian's name understand a medical student / nursing student may be present during my operation.
(To be completed by parent or guardian if patient is under the age of 18 years).The supply of information by you is voluntary, except where required under law. However, should you not supply the information, or supply only part of it, it may compromise your treatment while a patient at the Mildura Health Private Hospital.I, patient / parent / guardian's name acknowledge I have been informed of the following in regard to the collection of health information:
I understand the above points and agree to the collection of health information to assist in the provision of my care.
Reason for admission (please document in your own words why you are being admitted to hospital)reason for hospitalisation*
Please indicate YES or NO if you have suffered from any of the following:
Do you have any of the following?
To assist with planning for your hospitalisation and safe return home, please complete the following:
Follow this link to view the above documents online
After you have submitted this form, you will receive a link to download relevant patient information and resources.
The day prior to your procedure, we will SMS you with details of your admission time and fasting times.
Should you have any questions, please do not hesitate to contact us on 03 5022 2611 or email at email@example.com.