Healthcare Anaesthetic Form

HEALTHCARE ANAESTHETIC CONSENT AND ASSESSMENT

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance and Responsible Party

Procedure and Anaesthetic Plan

Surgeon / Proceduralist:    Scheduled Date:

Planned Anaesthetic Technique (check all that apply):

General anaesthesia    Regional block / spinal / epidural    MAC / Sedation    Local anaesthesia only

Planned Airway Management:

Endotracheal tube    Laryngeal mask airway    Face mask only    NA / Not applicable

Medical History & Assessment

Significant Past Medical History (check all that apply)

Diabetes    Hypertension    Heart disease    Respiratory disease

Renal disease    Bleeding disorder    Neurological disorder    Other

No    Yes — if yes, describe below

Height:    Weight:    BMI:

Airway / Exam Findings

Mallampati classification: I II III IV

ASA Physical Status (check one)

ASA I    ASA II    ASA III    ASA IV    ASA V    ASA VI

Fasting, Medications, and Special Considerations

I confirm that I have been instructed regarding NPO requirements and last intake: Last solid food: ; Last clear fluids:

Are you pregnant or could you be pregnant? No    Yes

Risks, Benefits and Alternatives

I acknowledge that the anaesthesia provider has explained the nature and purpose of the proposed anaesthetic care, the expected benefits, and the risks including but not limited to: allergic reactions, nausea and vomiting, sore throat, dental or airway injury, nerve injury or prolonged numbness or weakness, aspiration of stomach contents, respiratory failure, cardiac arrest, stroke, brain injury, permanent disability, or death. I understand that unpredictable complications can occur despite standard monitoring and care.

Alternatives to the proposed anaesthetic technique, including local anaesthesia only, regional techniques, different sedation levels, or no anaesthesia, have been discussed. I understand no guarantee can be made about the outcome and additional interventions may be necessary during the procedure.

I authorize the anaesthesia team to perform such additional procedures and to administer medications considered necessary for my safe management during the perioperative period, including blood products if required.

Patient Acknowledgement and Consent

By signing below I certify that I have read (or had read to me) and understand the information on this form, that my questions regarding the anaesthetic care have been answered to my satisfaction, and that I voluntarily consent to the administration of anaesthesia and related care described above. I understand I have the right to refuse or withdraw consent prior to initiation of anaesthesia.

I give permission for routine monitoring, intravenous access, and medications necessary for anaesthesia and perioperative care. I consent to postoperative analgesia as required for comfort and recovery.

This consent remains effective unless revoked in writing, or until the procedure and related anaesthetic care are complete, or on the specified expiration date below.

Privacy and Release

I acknowledge that the anaesthesia team may document details of my care in the medical record. I authorize disclosure of anaesthesia-related information to other health care providers involved in my care and to billing and administrative personnel as needed for treatment and payment. I understand my rights concerning privacy and the handling of my health information.

I acknowledge receipt of the anaesthesia privacy notice and consent to the use and disclosure described above.

Additional Notes / Provider Instructions

Sign Now