Anesthesia Pregnancy Risk Acknowledgment Form
By signing this form, you acknowledge that receiving any form of anesthesia carries risk to a fetus. You should not receive anesthesia if you are pregnant. You agree it is your responsibility to ensure you are not pregnant prior to receiving an anesthetic, and you agree to take a pregnancy test within 24 hours of your procedure and notify Illumination Anesthesia of a positive result. If you have not taken a pregnancy test within 24 hours, you agree to let your anesthesia provider know so that a pregnancy test may be administered immediately prior to your anesthetic.
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Brenna Burnette, CRNA | 970-703-5440 | illuminationanesthesia@gmail.com
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