I, the undersigned, acknowledge and understand that:
The purpose and nature of anesthesia have been explained to me. I understand that
anesthesia involves the use of drugs/techniques to prevent pain and awareness during surgery.
Anesthesia is an independent medical service separate from the surgical procedure,
provided by an anesthesia care team.
The choice of anesthesia technique is determined by the anesthesiologist based on
my medical condition and the surgical requirements.
While standard procedures are followed, the anesthesia plan may need to be modified
(e.g., converting from sedation to general anesthesia) if medical necessity arises during the procedure.
Vital signs and body functions will be monitored continuously during the procedure.
Medical students or residents may participate in my anesthesia care under the
direct supervision of the attending anesthesiologist (if applicable at this facility).
I have had the opportunity to ask questions, and they have been answered to my
satisfaction.
4. Risks and Possible Complications
I understand that while anesthesia is generally safe, it carries risks ranging from minor side effects to
life-threatening complications.
Common Side Effects (Temporary):
Nausea and Vomiting (PONV)
Sore throat / Hoarseness
Dizziness / Drowsiness / Confusion
Shivering / Muscle aches
Pain/Bruising at injection sites
Specific Risks (Less Common):
Dental injury (chips, loose teeth) or lip trauma
Urinary retention (inability to pass urine)
Corneal abrasion (eye scratch)
Awareness (recalling events during surgery)
Serious / Rare Complications: I understand rare but serious risks exist, including but not
limited to:
Severe Allergic Reaction (Anaphylaxis)
Aspiration Pneumonia (stomach contents in lungs)
Nerve injury / Paralysis
Malignant Hyperthermia (rare genetic reaction)
Stroke / Brain Injury
Heart Attack / Cardiac Arrest
Severe breathing difficulties / Prolonged ventilation
Death
5. Additional Risks for Regional / Neuraxial Anesthesia (If Applicable)
In the event of significant bleeding, blood transfusion may be lifesaving.
I CONSENT to the administration of blood or blood products if
deemed medically necessary by the anesthesia/surgical team. Risks (infection, reaction, overload) have been
explained.
I REFUSE blood products (e.g., Jehovah's Witness). I understand
this refusal increases the risk of serious morbidity or death.
7. Consent for Anesthesia
I certify that I have read (or had read to me) the contents of this form. The anesthesia plan, its benefits,
significant risks, and alternative options (including no anesthesia) have been explained to me. I have had the
opportunity to ask questions, and all my questions have been answered satisfactorily. I voluntarily consent to the
administration of anesthesia.
Patient / Legal Guardian Signature
Relationship (if not patient)
Date & Time
Witness Signature (If patient unable to sign/illiterate)
Witness Name (Print)
8. Anesthesiologist Declaration
I have explained the proposed anesthesia plan, benefits, significant risks, and alternatives to the
patient/guardian. To the best of my knowledge, the patient understands this information and has voluntarily
consented.
Anesthesiologist Name (Print)
License No.
Signature
Date & Time
Interpreter Declaration (if applicable): I have faithfully interpreted the information to the
patient in (language).
