Medical Consent

I, do hereby agree and acknowledge that my provider has explained to me that I will have an operation, procedure, diagnostic, or other treatment. My provider has explained the risks of that procedure, advised me of alternative treatments, and told me of the expected outcomes and what to expect if my condition remains untreated. I understand anesthesia services for the procedure will be provided by Illumination Anesthesia.

I understand that ALL FORMS OF ANESTHESIA INVOLVE SOME RISKS and no guarantees or promises can be made concerning the results of my procedure or treatment. Although rare, unexpected severe complications with anesthesia can occur and include the remote possibility of infection, bleeding, drug reactions, blood clots, loss of sensation, loss of limb function, paralysis, stroke, brain damage, heart attack or death. I understand that these risks apply to all forms of anesthesia. While every effort will be made to provide the level of anesthesia desired by the patient and the surgeon/proceduralist, I acknowledge that anesthesia is a continuum and some instances may require my anesthesia provider to give more or less anesthesia to keep me safe and provide more ideal operating conditions.

I acknowledge that general anesthesia is expected to render me totally unconscious, that a device may be placed in my oral cavity or trachea to assist with breathing. I acknowledge this breathing tube/device may be placed either in my mouth or my nose with the assistance of a laryngoscope. I understand an intravenous catheter will be used for the injection of drugs into my bloodstream to render me unconscious, treat pain, and stabilize my vital signs while under the effects of anesthesia. I understand that for procedures exceeding 4 hours in length, a foley catheter may be placed into my bladder to help prevent bladder injury. I acknowledge that general anesthesia has risks that include mouth or throat pain, damaged teeth, hoarseness, infection, awareness under anesthesia, injury to blood vessels or nerves, aspiration, pneumonia, cardiovascular or pulmonary complications, and life threatening complications. I understand this is not to be considered a comprehensive list of all potential complications from anesthesia. I acknowledge that in rare instances, my anesthesia provider may deem it necessary to transport me to a hospital via EMS and accept that all costs arising from additional care are my responsibility and not that of Illumination Anesthesia.

I acknowledge that monitored anesthesia care (MAC) is intended to reduce anxiety and discomfort during my procedure, that I may have some or total recollection of the procedure. I acknowledge that MAC anesthetics may intentionally or unintentionally convert to general anesthesia and therefore all the risks associated with general anesthesia also exist with lighter levels of sedation.

I hereby consent to the anesthesia services of Illumination Anesthesia and/or contractors of Illumination Anesthesia. I consent to alternative types of anesthesia and all lifesaving treatments and actions as deemed necessary by my anesthesia provider.

Illumination Anesthesia Medical Consent Form |970-703-5440 | illuminationanesthesia@gmail.com

I certify and acknowledge that I have read this form or had it read to me; that I understand the risks, alternatives and expected results of the anesthetic I have chosen to have. I acknowledge that I have had, or will have, an opportunity to ask questions and receive adequate answers to my questions and time to consider my decision.

Illumination Anesthesia Medical Consent Form |970-703-5440 | illuminationanesthesia@gmail.com