Please find below the anaesthetic consent document. Complete and submit prior to your procedure

1. You need to be starved for all anaesthetics and sedation for your own safety. No food or liquids (excluding clear fluids) may be taken by mouth for at least six (6) hours before the anaesthetic or sedation.

2. Water or apple juice may be taken up to two (2) hours before the anaesthetic unless otherwise instructed.

3. It is against the law to drive a motor vehicle or operate heavy machinery for 24 hours after the anaesthetic.

4. It is also recommended that no alcohol be taken, and no important decisions be made within 24 hours after the anaesthetic.

5. Medical history: You will be required to complete a medical questionnaire before your procedure. Please bring information on any medical conditions and results of relevant investigations you may have when you are admitted for your procedure.

6. Medication:

• Bring your current medication to the hospital if there is any chance that you will be staying overnight or need to take this medication while in hospital.
• Bring a list of any medication that you are currently on or have taken in the past 3 months (including homeopathic and natural products
• Take your routine medication as normal unless otherwise instructed. (If you are taking Warfarin, Aspirin, Plavix or any other blood thinners please ask your doctor when you should stop these before the operation

7. Timing of your procedure:

• Your procedure may be hours after the scheduled start time due to often unforeseen uncontrollable circumstances.
• If you are admitted later than the start time of a list, you may only see the anaesthesiologist in the theatre waiting area.
• If you have a medical condition or want to discuss anything with the anaesthesiologist please either make contact before the day of surgery or ensure you are admitted to the ward at least one hour before the start of the list. 

8. Complications during anaesthesia:

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

The following list covers some of the complications that may occur under anaesthesia, post operatively or due to side effects or interactions of post-operative medication.

Complications arising due to procedures that may be performed during your anaesthetic

A. Coding & Tariff Determination

1. The Practice determines the costs associated with the provision of anaesthetic services by using the coding rules as determined by the Health Professionals Council of South Africa (HPCSA), the South African Medical Association (SAMA) and South African Legislation (Health Act and Medical Schemes Act).

2. A specific Medical Aid may not recognise the validity of any or all of these codes as used by the Practice.

3. The Practice will assume that the rules and guidelines as determined by SASA and SAMA as the correct and ethical interpretation.

4. The Practice’s anaesthetic fee is determined by the anaesthesiologist based on training, expertise, experience and practice costs and do not relate to any medical scheme rate (Competition Commission ruling 2006). The rates used to determine the fee is applicable to all patients, irrespective of circumstance or medical aid membership as required by the Consumer Protection Act.

5. The cost of an anaesthetic is dependent on time and procedure complexity. As it is impossible to predict how long a procedure will take, it makes estimating the cost of an anaesthetic extremely difficult. A cost estimate may be requested before the procedure from AMS.

6. The cost may increase according to the duration of the procedure, procedures performed, risk factors and/or complications in theatre.

7. Explanations of the codes on the account can be obtained from the South African Medical Association (www.samedical.org), your medical scheme or the South African Society of Anaesthesiologists (www.sasaweb.com).

8. Your medical aid will reimburse you for your anaesthetic account at a rate based on the insurance plan you have selected and the rules of your medical aid. The total amount may not be covered by your medical aid and you will be responsible for any shortfall.

9. The anaesthesiologist is not a designated service provider (DSP) of any medical insurance company thus prescribed minimum benefit (PMB) conditions may not be covered by your medical insurance.

B. Account Administration & Terms of Payment

1. The administration of an account remains the responsibility of the patient and/or guarantor.

2. In cases where a funder’s administration is substandard or payments from the funder are paid directly to the patient, the Practice will NOT submit the account to the funder but directly to the patient/guarantor.

3. The Practice may only accept payment from the patient and/or the patient’s guarantor and/or a medical funder registered as such with the Council of Medical Schemes.

4. The patient and/or guarantor and/or employer (IOD cases) remains responsible for the full amount of the account.

5. Terms of full payment is strictly 30 (thirty) days after service delivery. After which the account will be handed over for debt recovery and interest will be charged at 2% per month. All costs incurred to collect the arrears will be for your account on attorney and client scale.

6. The Practice will NOT supply motivations to Medical Aids and/or Hospitals for the use of any medication and/or procedures and/or equipment that may be required during the course of the anaesthetic. In case the Medical Aid refuses to pay for clinically accepted treatments, you are advised to contact the Council of Medical Schemes (www.medicalschemes.com).

Contract with the Anaesthesiologist

1. I understand that the anaesthetic account is separate from the hospital and surgeon accounts.

2. I accept responsibility for the full amount of the anaesthetic account.

3. I understand that all EFT payments must be accompanied by the correct reference number, and that the anaesthesiologist will not be held responsible for any costs associated with payments that could not be allocated due to incorrect reference numbers.

4. I declare that the anaesthetic account will not form part of any administrative order that exists on the guarantor’s name.

5. I declare that all personal information supplied by me is true and correct. (Domicillium citandi et executandi)

6. I accept responsibility for all legal and tracing costs that may be incurred due to non-payment according to attorney and client scales.

7. I declare that, in case that I am not the guarantor, I have the permission of the guarantor to sign this contract.

8. I have read and understood the complete contents of this document and that I accept all terms and conditions as specified under “Billing Information”

Informed consent for Anaesthesia

1. I understand that a qualified Anaesthesiologist (specialist in Anaesthesia) will take responsibility for my peri-operative care to the best of his/her human abilities.  I understand that an incident-free anaesthetic is the aim but cannot be guaranteed.

2. I understand that receiving anaesthesia will have certain risks and that no guarantee can be given regarding my response to drugs administered during the anaesthetic.

3. I understand that during the procedure, my physical and surgical conditions may alter and require changes in the management of my anaesthesia. This will be done with my safety and wellbeing as the first consideration.

4. I understand that the transfusion of blood and/or other blood products may be required during the procedure. If you choose to refuse transfusion of blood products please inform your anaesthesiologist beforehand.

5. I consent to HIV and Hepatitis B testing in the event of contamination of a health care worker by human bodily fluids during the procedure.

6. I understand that anaesthetic staff and equipment are supplied by the hospital and cannot be guaranteed by the anaesthesiologist. Equipment is checked on a daily basis.

7. I, the patient / guardian authorise the anaesthesiologist to share relevant personal and/or clinical information with other healthcare organisations and the patient’s guarantor as required by law.

8. I agree to the processing of my health and personal information as contemplated in the Protection of Personal Information Act No 4 of 2013 by the Anaesthesiologist, practice staff and third parties, in order to provide proper treatment and care, as well as communicating with other persons inasmuch as it relates to my management, and/or for the administration of the institution or professional practice concerned. This consent would extend to responsible parties acting as service providers to the institution or professional practice concerned and medical schemes and their administrators where relevant. For a detailed notification of the personal information being collected a privacy notice may be requested from AMS (service provider).

9. In the event of any claim, complaint or grievance, I shall prior to taking any legal action, promptly initiate a free and confidential pre-mediation meeting with an accredited mediator appointed by SASA.

10. I have read and understood the information contained under “General Information”. I have been given the opportunity to discuss my concerns with the anaesthesiologist.

11. I declare that I am 18 years of age or older, of sound mind at the time of signing this agreement and that I am not under duress. I hereby give permission for the administration of anaesthesia on myself/ my dependent.