Dr H.S. Habangana Anaestheic Consent Form

1
Patient Name* This field is required.
Mr.
Mr.
Mrs.
Ms.
Dr.
Prof.
Hon.
Prefix
First Name
Last Name
2
Patient date of birth* This field is required.
e.g. 1 January 1980
3
Patient age
e.g. 23
4
I have a
RSA ID Number
Passport
5
RSA ID Number(Enter D.O.B for children less 1 year)
RSA ID Number
6
Passport Number(Enter D.O.B for children less 1 year)
7
Is the patient responsible for the account?
Yes
No
8
Main Member Name
Mr.
Mr.
Mrs.
Ms.
Dr.
Prof.
Hon.
Prefix
First Name
Last Name
9
Main member I.D. Number or Date of Birth
RSA ID number or DOB
10
Email
example@example.com
11
Phone Number
Country code e.g. +27
Phone Number
12
Emergency Contact Name* This field is required.
First Name
Last Name
13
Emergency Contact Number* This field is required.
Country code e.g. +27
Phone Number
14
Relationship* This field is required.
Spouse
Father
Mother
Brother
Sister
Child
Other
15
Do you have medical aid?
Yes
No - I will be paying privately
16
Medical Aid Scheme
e.g. Discovery
17
Medical Aid Plan
e.g. Classic Comprehensive
18
Medical Aid Number
e.g. 1234567890
19
Do you have GAP cover?
Yes
No
20
Please note: that we are not contracted with GAP cover and all payments by GAP cover will be made directly to you. You will be required to settle any medical aid shortfall with us and then claim back from your GAP cover.
21
Do you have any chronic illnesses?
Yes
No
22
Chronic illness detailsList your chronic illness here
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Small
Ok
Ok
23
Do you take any medication or vitamins?over-the-counter/ herbal / supplements
Yes
No
24
Medication or VitaminsList of medication/vitamins
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Small
Ok
Ok
25
Do you use ozempic / saxenda or other weight loss injections
Yes
No
26
Weight loss injection detailsDuration of treatment, Last injection and dosage
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Small
Ok
Ok
27
Do you have false, loose, crowned or chipped teeth?
Yes
No
28
False, loose, crowned or chipped teeth Details
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Small
Ok
Ok
29
Are you pregnant?
Yes
No
30
Pregnancy details
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Small
Ok
Ok
31
Do you experience heartburn or have gastro-oesphageal reflux disease?
Yes
No
32
Heartburn or gastro-oesphageal reflux details
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Small
Ok
Ok
33
Do you have any allergies?* This field is required.
Yes
No
34
Allergy details* This field is required.
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Small
Ok
Ok
35
Have you had any previous anaesthetics?
Yes
No
36
Please specify when and for what operations/procedures
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Ok
Ok
37
Have you had any problems with previous anaesthetics?
Yes
No
38
Please detail any problems with previous anaesthetics
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Small
Ok
Ok
39
Do you know if you or a family member has porphyria, malignant hyperthermia or scoline apnoea?
Yes
No
40
Porphyria, Malignant Hyperthermia or Scoline Apnoea details
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Small
Ok
Ok
41
Do you smoke?Hooker pipe/ Hubbly /Vaping / Cigarette/ Second hand smoke exposure
Yes
No
42
How many per day and for how many years?If hubbly/hooker pipe/vape/ 2nd hand smoke give details
43
What is your Alcohol Consumption?
Nil
Social
Moderate
Heavy
44
Do you use cannabis / gummies / recreational drugs
Yes
No
45
Please provide details so the Doctor can adjust your dose of anaaestheticYou may need more anaesthetic than the average person to achieve the same result
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Small
Ok
Ok
46
Have you had Cortisone/Steroid Treatment in past 12 months?
Yes
No
47
Cortisone/Steroid Treatment details
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Small
Ok
Ok
48
Have you recently had a cold, cough or flu?
Yes
No
49
Give details of recent cold, cough or fluHow long ago? Still coughing or runny nose? Admitted or treated at home? Covid tested?
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Small
Ok
Ok
50
Please enter your weight and height in centimetersUse last known parameters
51
Is there anything else you feel your Doctor should know?
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Ok
Ok
52
Please carefully read the Informed Billing Consent* This field is required.A copy of this form will be emailed to you
53
POPI Consent* This field is required.
54
I have accurately completed my medical history and have read and understood the cost estimation, POPI and billing consent* This field is required.
Yes
55
Please carefully read the Consent for Anaesthesia Services* This field is required.
56
I hereby consent to the anaesthesia service above and authorise that it be administered. I also consent to an alternative type of anaesthesia, if necessary, as deemed appropriate* This field is required.
Yes
57
Do you give consent for the transfusion of blood and blood products when indicated and necessary?* This field is required.Your surgeon will discuss the likelihood of bleeding and the need for transfusion for your specific procedure
YESNO
58
Capacity* This field is required.What is your relationship with the patient?
I am the Patient
Parent
Spouse
Legal guardian
Relative (child/sister/brother/aunt/uncle/grandparent)
59
Please enter your full name and ID number * This field is required.Required when consenting on behalf of the patient
60
Today's Date and Time* This field is required.
61
Signature - Please use your finger or computer mouse to sign* This field is required.
Should be Empty: