ANESTHESIA CONSENT FORM
Because you, in consultation with your surgeon, have decided to have surgery
requiring anesthesia, IT IS IMPORTANT THAT YOU, THE PATIENT, READ THIS
CONSENT FORM CAREFULLY.
General anesthesia involves making the patient unconscious using intravenous drugs
(such as sedatives, narcotics, and muscle relaxants) and inhalational agents (such as
nitrous oxide, oxygen, and anesthetic gases). This frequently involves the use of a
breathing tube, which is inserted into the windpipe to insure proper breathing while
you are under anesthesia. It is not possible to inform you of every agent to be used or
dosage to be given since this is determined by the patient's reactions and the needs
of surgery.
Side effects and complications of general anesthesia are relatively uncommon, but
can occur. While it is impossible to advise you of every conceivable complication,
some possible examples are;
Soreness of the throat and hoarseness are very common occurrences.
Aspiration (inhaling stomach contents into the lungs), asthma attacks, and
Pneumonia.
Nerve injuries and possible weakness or paralysis.
Allergic-type reactions leading to cardiac arrest and death.
Nodules, polyps, or other damage to the vocal cords or windpipe.
Possible traumatic damage to larynx (voice box), pharynx (throat), esophagus,
lung or surrounding structures.
Blood transfusions may be required. If so, there is some risk of hepatitis, AIDS, or
other infections or reactions. No tests exist which can prevent every possibility of
blood infected with hepatitis or AIDS being transfused.
Rarely, there may be recall of events during the procedure. This is more common
during anesthesia for cesarean section, heart and emergency surgery.
Sometimes dreams during anesthesia are confused with recall of real events.
A breathing machine may be required after surgery, which could lead to damage to
the windpipe.
Medical complications involving damage to the eyes, heart, lungs, and circulatory
system such as blindness, stroke, blood clots, abnormal heart rhythms,
phlebitis, collapsed lung, and heart attack.
Possible traumatic injury to the jaw which may include dislocation, arthritis,
temporomanidibular joint (TMJ) disorder or chronic pain.
Teeth and dental prosthetics may become loose, broken, or dislodged,
especially if loose or in poor repair regardless of the care provided by the
anesthesiology provider. By signing this consent you are acknowledging that your
anesthesia providers and Martin Memorial Health Systems will not be liable for any
dental damage or repairs.
MAC (Monitored Anesthesia Care): MAC is not General Anesthesia. MAC involves
local anesthesia or nerve blocks performed by
the surgeon, with monitoring of the patient's vital signs and selection and
administration of sedatives and tranquilizers by the anesthetist. Unlike General
Anesthesia, the patient maintains their heart and lung function without direct support
or intervention on the part of the anesthetist. The patient is usually very sedated, but
may still be able to hear and respond to their medical providers and remembers some
or all of their experience. In surgery of the eye, sometimes the anesthesiologist will
numb the eye with a nerve block and also provide Monitored Anesthesia Care. The
potential complications or side effects during MAC are the same as those reviewed
above and below for General Anesthesia and Regional Anesthesia.
Regional Anesthesia: Regional Anesthesia involves one of a number of methods for
producing numbness in the area of surgery and is performed by the anesthesia
provider. These methods include;
Local: Local anesthesia is injected into and around the area of the surgery to
produce numbness
Nerve Block: A nerve block involves the injection of local anesthetic around the
major nerves going to the area of surgery to produce numbness.
Intravenous regional: This technique involves the injection of a local anesthetic into
a vein in the arm or leg and keeping it there using a tourniquet, causing the arm
or leg to get numb.
Spinal: Spinal anesthesia involves injecting a local anesthetic directly into the fluid
surrounding the spinal cord in the back.
Epidural:Epidural anesthesia involves injecting a local anesthetic directly outside
the spinal canal in the epidural space. This is done in the back directly through
a needle and/or by threading a plastic tube (catheter) into the epidural space.
The needle is then removed, leaving the catheter in place. Local anesthetic
agents and/or narcotics are then injected through the catheter. This catheter
may be used postoperatively for pain control.
The intention of regional anesthesia is to produce numbness in the area of surgery.
Like Monitored Anesthesia Care, regional anesthetic methods are usually
supplemented by sedatives and tranquilizers which cause drowsiness or sleep. The
patient may still be able to hear and respond to their medical providers and
remembers some or all of his/her experience. In the vast majority of cases, these
techniques are safe, effective methods of providing surgical anesthesia. HOWEVER,
SOMETIMES THE ANESTHESIA IS NOT ADEQUATE OR WEARS OFF AND
SURGICAL ANESTHESIA MUST BE OBTAINED BY OTHER METHODS
INCLUDING GENERAL ANESTHESIA.
Side effects and complications of regional anesthesia are relatively uncommon, but
can occur. It is impossible to advise you of every conceivable complication, but some
possible complications are as follows:
Side effects: Swelling, tenderness, bleeding, and bruising at injection site,
nausea/vomiting.
Very uncommon: Shock or extreme fall in blood pressure, convulsion/seizure.
Extremely rare: Nerve damage resulting in numbness, tingling and/or paralysis,
which may be temporary or permanent. Respiratory arrest, cardiac
arrest/death, allergic reactions to drugs. in the case of eye blocks, blindness is
possible.
In addition to the above list, spinal/epidural anesthesia may also have the following
side effects and complications:
Side effects: Mild to moderate fall in blood pressure, headache.
Very uncommon: Headache from a "wet tap" (spinal tap) during epidural which
may be severe enough to require another epidural for treatment. Headache can
also occur after spinal anesthesia, shock or extreme fall in blood pressure and
very slow heart rate, high spinal anesthesia (anesthesia level is too high)
requiring breathing assistance.
Extremely rare: Broken epidural catheter.
Epidural hematoma (blood clot around spine).
Infection of the spine or meningitis.
Paralysis, which may be permanent, and include loss of bowel/bladder control.
Emergency surgery of the spine to prevent meningitis or paralysis.
In order to minimize the possibility of aspiration, the patient is required not to eat or
drink anything for a period of time before surgery. In elective cases, this is usually
from midnight prior to surgery. It is extremely important not to eat or drink anything
during this time because aspiration of undigested food or of significant quantities of
stomach contents can lead to severe pneumonia, respiratory failure, and death.
I understand that part of the anesthesia process may require the insertion of special
monitoring and /or fluid lines, such as an arterial line, central venous line or Swan
Ganz catheter. This will be discussed with you prior to insertion by the Anesthesia
personnel.
I understand that the surgeons will be occupied solely with the surgery and that the
administration, maintenance, and termination of anesthesia are independent functions
and will be supplied by, or under the direction and responsibility of, YOUR
ANESTHESIA PROVIDERS, WHICH INCLUDES ANESTHESIOLGISTS AND
CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNAs).
I have been informed that students may be performing some procedures, such as
insertion of fluid lines or performing endotracheal
intubation under the direct supervision of an Anesthesiologist.
I HEREBY CONSENT TO THE ADMINISTRATION OF ANESTHETICS AS MAY BE
CONSIDERED NECESSARY OR ADVISABLE.
_______ I have read this form or have had it read to me and fully understand the
above consent. I have had the opportunity to have my questions answered to my
satisfaction. The undersigned physician has fully explained the nature and expected
benefits, alternatives and risks involved in the anesthesia I have chosen. I hereby
consent to the administration of anesthetics as may be considered necessary or
advisable.
________As the patient's designated health care surrogate/proxy I have read this
form or I have had the opportunity to have the form read to me and fully understand
the above consent. I do not have any questions for the anesthesiologist. I hereby
consent to the administration of anesthetics as may be considered necessary or
advisable.
CONTACT NAME & NUMBER
_____________________________________________
______________________________________________ ________________
Signature of Patient Date/Time
______________________________________________
Witness to Signature
_______________________________________________ __________________
Signature of Individual with authority to sign State Relationship
_______________________________________________ __________________
Witness to signature Date/Time
__ "Language Line" SM used to interpret consent form for patient.
I hereby certify that the patient or one authorized to act in his/her behalf has been
informed, in lay terms understandable to the patient of the nature of the anesthesia
procedure, the alternatives as to treatment, and the consequences of and risks to the
patient inherent or associated with the procedure and anesthesia.
________________________________________________ _________________
Physician Signature Date /Time
MARTIN MEMORIAL HEALTH SYSTEMS
STUART, FLORIDA
ANESTHESIA CONSENT
RM055 New 10/05
G/Consent Forms/anesthesia 055 Rev 12/30/10; 1/18/10; 3/14/11; 7/11; 6/12
REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK
MANAGEMENT.
PPATIENT LABEL
BLOOD TRANSFUSION CONSENT / REFUSAL
I have been fully informed of my medical condition by my physician and I have been
advised that I may need blood transfusion therapy in the course of my treatment. The
amount of blood I am given will be determined by my treating physicians, depending on
my need.
I understand that blood is administered intravenously with sterile equipment. Blood and
blood components are provided to Martin Memorial Health Systems by the Central
Florida Blood Bank. The blood is supplied by the community volunteer donor pool. The
blood and blood products are tested and screened for infectious diseases by the Central
Florida Blood Bank and by the Martin Memorial Health Systems Blood Bank. The
testing is done in accordance with the American Association of Blood Banking, which is
regulated by the FDA. I understand that blood transfusion therapy is a common
procedure and that it is the only medical treatment which effectively and rapidly replaces
excessive blood loss. The possible complications of not receiving blood or blood
products range from a delay in recovery to death. Though rare, blood transfusion
therapy has potential risks such as discomfort at the site of administration, fever,
mild skin reactions, swelling, bruising, allergic reactions with symptoms ranging
from mild to severe, even death for unknown reasons, heart failure due to
circulatory overload, infectious diseases, such as acquired immunodeficiency
syndrome (AIDS), viral hepatitis, both of which may be fatal, bacterial
contamination with septic and toxic reaction.
If blood transfusion therapy is needed for elective surgery, I may choose to give my own
blood if I meet the medical criteria for autologous transfusion or I may choose to have
blood donated by family or friends with my same blood type for my use. Autologous and
designated donor blood must be arranged in advance and these alternative methods of
transfusion carry the same risks as those stated above.
CONSENT FOR BLOOD TRANSFUSION
This information has been explained to my satisfaction and I have been given ample
time to ask questions of my physician. I have been advised of the risks, benefits and
alternatives by my physician and understand the risks and implications of blood
transfusion therapy. I hereby consent to any blood transfusion deemed necessary by
my physician.
I authorize my physicians and Martin Memorial to disclose health information related to
this treatment or procedure to any friend or family member who has accompanied me or
who is waiting for me, even if I am competent or available, with the exception of the
following:
___________________________________________________________.
Previous reaction to blood transfusion? ( ) Yes ( ) No
What was the reaction?
_____________________________________________________
__________________________________________ ___________________
Patient/Authorized Surrogate or Proxy Signature Date/Time
__________________________________________ __________________
Witness Signature Date/Time
================================================================
REFUSAL OF BLOOD TRANSFUSION
I have been advised that my physician has recommended a blood transfusion. I request
that no blood or blood products be administered to me. I understand that refusal of such
treatment has risks which have been explained to me by my physician. These risks may
range from a delay in recovery to death. I hereby release my physicians, Martin
Memorial Health Systems, and its personnel, from any responsibility or liability for the
consequences of such refusal on my part.
___________________________________________ __________________
Patient/Authorized Surrogate or Proxy Signature Date/Time
___________________________________________ __________________
Witness Signature Date/Time
□ “Language Line” SM used to interpret consent form for patient.
SPECIAL PROCEDURE CONSENT FORM
I have read, or have had read to me, and understand the following authorization for
______________________________________________________________________
______________________________________________________________________
I authorize Dr. __________________________________
to perform the above described procedure or treatment.
I have discussed my medical condition, the proposed treatment or procedure,
alternatives to this treatment and the risks associated with them with my physician. I
have been informed that in the performance of any invasive procedure, there is the
potential for damage to my organs, nerves, and blood vessels, allergic reaction, blood
clots, inadvertent puncture, laceration, infection, consequent hemorrhage, and very
rarely death. I fully understand that it may be necessary to proceed with additional
procedures, or possibly surgery, to repair the injury or control and treat the complication.
I specifically request my physician to proceed with whatever is deemed medically
necessary and request that I be given a full explanation after the effects of sedation
have subsided.
I agree to the administration of blood or blood products if they are required. (Potential
risks of blood transfusions include the risk of hepatitis, AIDS, or other infections or
reactions).
I agree to the administration of contrast (IV dye) if required. (Potential risk of contrast
reaction).
I agree that any tissue or parts surgically removed may be disposed of in accordance
with the hospital’s accustomed practice.
I agree that my physician may permit photographs or video tapes of my procedure or
treatment, employing appropriate privacy draping of my person, to record the procedure
for the express purpose of medical education or to provide a record to be filed with strict
confidence with my medical records.
I have been informed that other practitioners may be performing important aspects of
the procedure, administering anesthesia or implanting devices that are within their
scope of practice.
I consent to the observation of my procedure or treatment by individuals for the
purposes of medical education and to the presence of a medical representative in the
operating/procedure room. I understand medical representative to mean non-medical
technician of companies which have furnished operating room/procedural equipment
and supplies.
During this procedure I may receive MODERATE SEDATION which is a drug-induced
depression of consciousness during which patients respond purposefully to verbal
commands, either alone or accompanied by light tactile stimulation. No interventions are
usually required to maintain a patent airway, and spontaneous ventilation is adequate.
Cardiovascular function is usually maintained. The patient is usually very sedated, but
may still be able to hear and respond to their medical providers and remembers some
or all of their experience. Side effects and complications of moderate sedation are
relatively uncommon but can occur. While it is impossible to advise you of every
conceivable complication, some possible examples are;
• Progression to a deeper level of sedation.
Soreness of the throat and hoarseness are very common occurrences
• Aspiration (inhaling stomach contents into the lungs), asthma attacks,and pneumonia.
• Nerve injuries and possible weakness or paralysis.
• Allergic-type reactions leading to cardiac arrest and death.
• Nodules, polyps, or other damage to the vocal cords or windpipe.
• Sometimes dreams during anesthesia are confused with recall of real events.
• Medical complications involving damage to the eyes, heart, lungs, and circulatory
system such as corneal abrasions, blindness, stroke, blood clots, abnormal heart
rhythms, phlebitis, collapsed lung, and heart attack.
• Possible traumatic injury to the jaw which may include dislocation, arthritis,
temporomandibular joint (TMJ) disorder or chronic pain.
Teeth and dental prosthetics may become loose, broken, or dislodged, especially if
loose or in poor repair regardless of the care provided by the provider. By signing this
consent you are acknowledging that your providers and Martin Health System will not
be liable for any dental damage or repairs.
I have had the opportunity to have my questions answered to my satisfaction.
I authorize my physicians and Martin Memorial to disclose health information related to
this treatment or procedure to any friend or family member who has accompanied me or
who is waiting for me, even if I am competent or available, with the exception of the
following:
______________________________________________________________________
_____________________________________________ _________________
Patient/Authorized Surrogate or Proxy Signature
Date/time
_____________________________________________ _________________
Witness Signature Date/time
I certify that I have explained the nature, purpose, benefits, risks, complications, and
alternatives to the proposed procedure as well as the risks, benefits and alternatives of
moderate sedation to the patient or the patient's legal representative. I have answered
all questions fully, and I believe that the patient / legal representative fully understand
what I have explained. I further certify that I have validated the procedure/site and side
and that the correct procedure site has been marked, if indicated, prior to the procedure
being performed. The patient has been evaluated and is a candidate for moderate
sedation.
_____________________________________________ _________________
Practitioner Signature
□ “Language Line” SM used to interpret consent form for patient.
PATIENT LABEL
Date/time
MARTIN MEMORIAL HEALTH SYSTEMS
STUART, FLORIDA
SPECIAL PROCEDURE CONSENT
RM058 4/01, 7/07, 10/08, 1/10, 8/11, 5/13
REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK MANAGEMENT.
SURGERY CONSENT FORM
DO NOT SIGN WITHOUT READING!
I have read, or have had read to me, and understand the following authorization for:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I authorize Dr. ________________________________________to perform the above
described procedure or treatment.
I have discussed my medical condition, the proposed treatment or procedure,
alternatives to this treatment and the risks associated with them with my physician. I
have been informed that in the performance of any invasive procedure, there is the
potential for damage to my organs, nerves, or blood vessels. There is also the
possibility of an allergic reaction, blood clots, inadvertent puncture, laceration, infection,
consequent hemorrhage, dislodgement or displacement of implanted devices, paralysis,
and very rarely death. I fully understand that it may be necessary to proceed with
additional procedures to repair an injury or control and treat the complications. I
specifically request my physician to proceed with whatever is deemed medically
necessary and request that I be given a full explanation after the effects of sedation
have subsided.
I agree to the administration of blood or blood products if they are required. (Potential
risks of blood transfusions include the risk of hepatitis, AIDS, or other infections or
reactions.
I agree that any tissue or parts surgically removed may be disposed of in accordance
with the hospital's accustomed practice, which may or may not include utilizing any
tissue not needed for my care for general research. No personal information will be
shared.
I agree that my physician may permit photographs or video tapes of my procedure or
treatment, employing appropriate privacy draping of my person, to record the procedure
for the express purpose of medical education or to provide a record to be filed with my
medical records.
I consent to the observation of my procedure or treatment by individuals for the
purposes of medical education and to the presence of a medical representative in the
operating room. I understand medical representative to mean non-medical technician of
companies that have furnished and may assist with operation of operating room
equipment and supplies.
I have been informed that other practitioners may be performing important aspects of
the procedure, such as opening and closing, dissecting tissue, removing tissue,
harvesting grafts, transplanting tissue, administering anesthesia, implanting devices and
placing invasive lines.
I have had the opportunity to have my questions answered to my satisfaction.
□ “Language Line” SM used for interpretation.
I authorize my physicians and Martin Memorial to disclose health information related to
this treatment or procedure to any friend or family member who has accompanied me or
who is waiting for me, even if I am competent or available, with the exception of the
following:
______________________________________________________________________
________________________________________ ________________________________
Patient/Authorized Surrogate Or Proxy Signature
Date/Time
________________________________________ __________________________
Witness Signature
Date/Time
I certify that I have explained the nature, purpose, benefits, risks, complications, and
alternatives of the proposed procedure to the patient or the patient's legal
representative. I have answered all questions fully, and I believe that the patient/legal
representative fully understands what I have explained. I further certify that I have
validated the procedure/site and side, and that the correct procedure site has been
marked, if indicated, prior to the procedure being performed.
__________________________________________ __________________________
Practitioner Signature
Date/Time
MARTIN MEMORIAL HEALTH SYSTEMS
STUART, FL
SURGERY CONSENT
RM056 Rev 11/00 2/01, 6/03, 10/05, 2/06, 3/07, 5/07, 4/08, 01/09; 7/11; 1/12; 5/12
G/Consent Forms/surgical consent 056
REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK
MANAGEMENT.
Patient Label
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