Consent for anaesthesia

Thank you for taking the time to complete this document.

The information contained in this document is important in facilitating a safe anaesthetic AND helps us to provide an efficient and professional service.

 

Please answer every question and do not withold any medical information. All information is treated with strict confidentiality.

 

For more information or queries please contact me on:

011 463 7821/4958

bradyudels@gmail.com

 

Eating before receiving anaesthesia or sedation

You need to be starved for all anaesthetics and sedation.

All patients

No food for 6 hours prior to your anaesthesia

you may drink clear fluid (water, apple juice, black tea or coffee) until 2 hours before your anaesthesia

Morning surgery – no food after 02h00. Clear fluid before 6am
Afternoon surgery – no food after an early light breakfast (before 7am). Clear fluids until 11am

Children under 12 years old must also have no food or milk products from 6 hours before admission, but may have water or clear apple juice up to 2 hours before admission to the hospital. Please discuss breastfeeding with the doctor.

With respect to anaesthesia for the procedure:

I acknowledge that I have received an anaesthetic information sheet with relevant information on risks associated with anaesthesia and associated cost estimate.
The nature of the anaesthetic and the risks and complications generally associated with anaesthesia and this procedure have been explained and clarified to me.
I understand that no one can guarantee an incident free anaesthetic and procedure.
There is equipment and theatre staff supplied by the hospital which cannot be guaranteed by the anaesthesiologist.
Certain drugs/monitors may be required for patient care which are considered ‘off-label’ or not funded by my chosen medical insurance.

I exempt the anaesthesiologist from any managed care requirements of my medical scheme.

I agree not to drive, operate dangerous machinery, drink alcohol or make important decisions for 24 hours after the recovery from anaesthesia or while taking medication prescribed to me by the anaesthesiologis

Complications during anaesthesia

Anaesthesia is not without risk. Adverse events can occur during any anaesthetic, which can range from trivial to brain damage or death. These events may occur due to: Reactions to anaesthetic drugs, underlying medical diseases, complications with procedures that have to be performed or due to surgery. Anaesthetists have been trained to manage these complications which may incur further medical expenses. If a complication persists for more than 48 hours please inform your anaesthesiologist or surgeon. 

Common complications (1-10% of cases) Minimal treatment usually	Rare complications (less than 1 in 1000 cases) May require further treatment	Very rare complications (1in 10 000-200 000 cases) Often serious with long term damage	Brain damage or death ( less than 1 in 250 000 cases)
Nausea and vomiting Sore throat Shivering or feeling cold Headache Dizziness Itching Pain during injection of drugs Swelling or bruising at the infusion site. Confusion or memory loss (common if elderly) Drug interactions	Injuries to teeth, crowns, lips, tongue and mouth Hoarse voice, voice changes Vocal cord injuries Painful muscles Difficulty in urinating Difficulty breathing Visual disturbances Worsening of underlying medical conditions like diabetes, asthma or heart disease	Eye injuries Nerve injuries causing paralysis Lung infection Awareness of the operation Bleeding Stroke Allergic reactions Unexpected reactions to anaesthetic drugs Inherited reactions to drugs (Malignant hyperthermia, Scoline apnoea, porphyria)	Due to any other complication getting more severe Heart attacks Abnormal heart rhythm Emboli (clots) Lack of oxygen which can result in brain damage Severe allergic reactions Aspiration pneumonia – stomach contents entering lungs

Procedural complications

 

Intravenous line ("drip")	Pain, swelling, bleeding, inflammation, infection, repeated insertions
central line for specialised therapy & monitoring	Pain, swelling, bleeding, inflammation, infection, repeated insertions,puncture of lung,artery or nerve
arterial line for specialised monitoring	Pain, swelling, bleeding, inflammation, infection, repeated insertions,nerve damage, loss of blood flow to the hand leading to death of fingers
airway management	Damage to lips, teeth, tongue, palate, throat, vocal cords, hoarseness, inhalation of stomach contents (aspiration), pneumonia, obstruction of breathing, failure to manage the airway which may require an emergency operative procedure.
nerve blocks, spinal or epidural injection	Nerve damage, paralysis, backache, headache, nausea, vomiting, dizziness, shortness of breath, pain, bleeding, inadequate pain control.

Confidentiality & Protection of Personal Information

I agree that personal information collected in terms of this consent is to be utilised for healthcare of the patient, billing and collection of debt as well as processing of queries, complaints and compliments.
I authorise release of any clinical information, including my HIV status to any other member of the medical/paramedical profession responsible for my safety and treatment.
I agree to allow my personal and clinical information to be shared with other persons or institutions (e.g. medical scheme) if this is necessary to serve a legitimate purpose within the ordinary course and scope of my anaesthesiologist's duties, provided such disclosure is in my/patient’s best interest.
I understand my personal information is stored in a secure location and is accessible only to 3rd parties with signed confidentiality clauses as part of their employment agreements/contracts.
I consent to sharing patient, guardian and guarantor information with the South African Society of Anaesthesiologists in the event of 
a complaint. This will remain confidential within the SASA CEO and Private Practice and Regulation Business Unit.

Invoice & payment

I understand & confirm:

The anaesthesiologist charges for his service independently from the surgeon and hospital
I understand that I am personally responsible for payment of the account and undertake to settle my account upon completion of service. If I fail to pay any amounts that are due, I agree that all amounts owing will immediately become due and payable and the anaesthesiologist or their nominated representative may access any of my available information and disclose my failure to pay or erratic payments to any credit bureaus or 3rd party without incurring any liability therefore. I will also be liable for interest, tracing fees, legal costs and collection fees.
That medical insurance companies offer cover at different rates. The medical insurance I have chosen may reimburse me at between 33% and the full amount of the estimated cost, dependent on my chosen plan.
The anaesthesiologist is not a designated service provider (DSP) of any medical insurance company and therefore prescribed minimum benefit (PMB) conditions may not be covered in full by my medical insurance (this is determined by the rules of my medical insurer).
Patients on Discovery Health Classic plans, Fedhealth and Netcare may be charged a scheme rate. Some medical aid plans may still require a co-payment in addition to the plans contribution.
International medical funds, private patients and certain medical fund plans may be subject to a higher rate (‘300% fee’) due to anticipated recovery costs and upfront quotations or motivations required.
The nominated address supplied on the hospital information sheet as my DOMICILIUM ET EXECUTANDI for all purposes under this agreement. I agree that any notice sent to the nominated address by registered post or email supplied will be deemed to have been received by me on the 3rd day after sending it. Any notice received by any means will be valid for legal purposes.
I nominate the party listed as ‘person responsible for payment’ of the account as the guarantor. The guarantor is aware of this responsibility.
A guarantor does not absolve me from my responsibility for payment and that I am bound by the terms of this agreement.

Payment agreement between the Anaesthesiologist and Patient/ Guardian / Guarantor

Anaesthesia costs are calculated according to established codes and practices governed by the Health Professionals Council of South Africa and relevant legislation (Health Act, Medical Schemes Act).
These costs include:
A time based component dependant on the length of time you are in the anaesthesiologist’s care
A higher fee for more difficult or complex surgery
Risk/expertise based modifiers including, but not limited to, age, obesity, blood pressure control, head & neck procedures, ICU admission, nerve blocks and emergencies
Procedures performed by the anaesthesiologist
Additional procedure costs or costs associated with unanticipated complications
A cost estimate assumes average surgical time and complexity. Additional fees will be charged if the procedure exceeds the average surgical duration, or if unanticipated complications arise or if additional treatment and procedures are performed.
I am aware that I have to determine the estimated duration of surgery from the anaesthesiologist or surgeon to obtain the total estimated cost of my anaesthesia.

Estimate of costs

Pre-anaesthetic consultation, prep & 1st 30 mins	R3700
First 60 minutes	R4800
Time fee per 15 minutes after 60 minutes	+R 1000

 

Emergency	R1000 +R700 per 30 mins
Epidural/spinal/nerve block/PCA	R1600
Arterial line/central venous catheter	R1000
Head or neck procedure	R900
Positioning/Age >70 or	R900
ICU or High Care	R2000
BP Control/ Obesity (BMI> 35)	R700 every 15 mins

Confirmation

I have received this consent form and information timeously. I understand the contents and agree to the queries/complaints procedure on the stated form.
I have had an opportunity to ask questions and obtain further information from my anaesthesiologist regarding this consent, anaesthesia and concerns specific to me.
I have been in possession of the anaesthesiologist’s contact details and I am able to contact him to discuss any concerns.
I have no further queries or disputes relating to this consent or the ‘Payment Agreement”
This agreement incorporates the Anaesthetic Independent Practitioner Association (AIPA) anaesthetic consent form or SA Society of Anaesthesiologists Anaesthesia form (green form) which shall have the same force and effect as if set out in the body of this agreement. 
I have read, understood and agree to the contents herein. I confirm that I am 18 years of age or older and the particulars and all information furnished by me are in all respects true and complete.