Healthcare Anesthesia Form

HEALTHCARE ANESTHESIA FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Do you have any of the following? (check all that apply)
Diabetes Hypertension Heart disease Asthma / COPD Bleeding disorder Pacemaker / ICD

Anesthesia Assessment

Weight:    Height:

Last oral intake (time and substance):    NPO since:

ASA Physical Status (select one): I II III IV V VI

Planned Procedure & Anesthetic Plan

Planned anesthetic technique (check all that apply):
General anesthesia Regional / Spinal / Epidural Monitored anesthesia care (MAC) / Sedation Local anesthesia with sedation Peripheral nerve block

Anticipated airway management: Endotracheal tube Laryngeal mask airway Mask ventilation

Risks, Benefits, and Alternatives

I acknowledge that the anesthesia care team has explained the purpose, expected benefits, significant risks, and reasonable alternatives to the proposed anesthesia. Significant risks include, but are not limited to: allergic reaction to medications, nausea and vomiting, aspiration of stomach contents, breathing difficulty requiring prolonged ventilation, infection, bleeding, nerve injury or permanent numbness, cardiac arrest, stroke, brain injury, and death. Regional techniques may be associated with temporary or permanent nerve injury, infection, bleeding near the injection site, or failure of the block.

I understand that no guarantee can be made that anesthesia will be free from complications and that additional interventions may be required during or after the procedure. I have been given the opportunity to ask questions and those questions have been answered to my satisfaction.

Alternatives to the proposed anesthetic plan, including regional techniques, local anesthesia, sedation-only approaches, or no anesthesia, were discussed and considered.

Additional Consents

I authorize administration of medications and supportive therapies as deemed necessary by the anesthesia team, including intravenous fluids, vasoactive medications, reversal agents, and medications for pain control. I consent to placement of monitoring devices, peripheral or central venous catheters, arterial lines, and urinary catheterization if required for my care.

Blood products: I consent to transfusion of blood and blood products as necessary. I refuse transfusion of blood and blood products. (If you refuse, please initial and discuss alternatives with the care team.)

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I consent to the anesthesia team obtaining and using my protected health information for my treatment and related health care operations.

I acknowledge receipt or offer of the privacy notice and consent to use of my health information as stated above.

Authorization Duration

This anesthesia authorization is effective for the date of the scheduled procedure and for any reasonable delays or related procedures during the same hospitalization or encounter unless revoked in writing. Authorization expiration date:

Patient Statement and Consent

I hereby authorize the anesthesia care team, including attending anesthesiologists, nurse anesthetists, and trainees, to provide anesthesia and related care as described above. I certify that I have read (or had read to me) the information on this form, that the nature of the proposed anesthesia, the anticipated benefits, the material risks, and the available alternatives have been explained to me, and that my questions have been answered. I understand that I may withdraw this consent at any time prior to administration of anesthetic agents by notifying my anesthesia provider, but that withdrawal may result in delay or cancellation of the procedure.

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