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Anesthesia Consent Form

9500 Roosevelt Boulevard, Philadelphia, PA 19115

To The Patient: This consent form confirms the discussion of the anesthesia care you will receive from Delaware Valley Anesthesia for your procedure.

    Patient Name* Date*

    Anesthesia Management: Dr. has explained that a member of Delaware Valley Anesthesia would monitor your bodily functions and administer anesthesia under the direct personal supervision of an attending anesthesiologist who may be assisted by other members of Delaware Valley Anesthesia.

    Types and Risks of Anesthesia: Anesthesia involves risks in addition to the risks of the procedure itself. The particular form of anesthesia planned for your procedure and the associated risks have been discussed with you as indicated below. The risks documented here are not all-inclusive and other unexpected risks or complications may occur.

    General Anesthesia makes you unconscious and insensitive to pain through the use of medications, which you may breathe or have injected. A breathing tube is usually placed into you windpipe once you are unconscious and later removed before you are fully awake. Occasionally, the breathing tube will remain in place a little longer until you are strong enough to breathe independently. Postoperative nausea or vomiting is common, but usually can be suppressed by medications. Some patients fear awakening during the surgery but this complication is very rare. The risks associated with general anesthesia include, but are not limited to, damage to lips or teeth, sore throat, headache, eye injury or blindness, infection, transfusion reactions (including excessive bleeding and kidney damage), drug reaction (including rash, shock, and cardiac/respiratory arrest), blood clots, lung infection, loss of sensation or limb function, paralysis, stroke or brain injury, heart failure or heart attack, and death.Regional Anesthesia involves injection of medication to temporarily numb a specific area of the body. Epidural, spinal, or selective nerve blocks are commonly used methods. As part of regional anesthesia, you usually receive medication to relax you. Occasionally, regional anesthesia does not provide sufficient pain relief. In these situations, you may receive general anesthesia or intravenous pain-relieving drugs to supplement regional anesthesia. An epidural catheter can also be placed in your back near the spinal nerves before surgery to provide you with more effective pain control after major abdominal or thoracic surgery. The risks of regional anesthesia include, but are not limited to, low blood pressure, itching or allergic reaction to drugs, obstructions or cessation of breathing, severe headache, temporary paralysis, nerve injury, infection or meningitis.Monitored anesthesia care (MAC) or monitored sedation involves the use of intravenous medication to calm you, and to make you less aware of the procedure. You may recall voices or have mild discomfort. The risks of MAC include, but are not limited to, allergic reactions to drugs, obstruction of breathing and nausea and vomiting after the procedure.Local Anesthesia is given by injection. It is generally given by the surgeon to numb a specific area.

    Acknowledgement and Consent for Anesthesia: I acknowledge that I have read and understand this form or it has been read to me) including all the medical terms about which I have asked if unsure, than all my questions about anesthesia have been answered by the anesthesiologist in a satisfactory manner, that I have honestly answered all health-related questions asked of me, and that I have been explained to my satisfaction all the risks & complications associated with anesthesia. I understand them and accept the risks. I likewise understand and accept the specific anesthesia plan selected for me as indicated above. I also acknowledge and understand that while I am under anesthesia, conditions may arise that requre the anesthesiologist to perform additional procedures that werenot planned when I signed this Anesthesia Consent form. This includes changing from one type of anesthetic to another or placement of additional invasive monitoring devices as medically indicated. Therefore, I authorize my anesthesiologist, other personnel who may be otherwise involved in administering my anesthesia, and all medical personnel under the supervision or control of my anesthesiologist to perform such additional procedures, as the anesthesiologist deems medically necessary.

    I voluntarily consent to the administration of anesthesia and to all procedures deemed medically necessary or appropriate by a member of Delaware Valley Anesthesia. This consent shall be valid until revoked by me in writing.

    E-Signature of Patient*

    Witness* Relationship to patient

    Signature of Authorized Representative*

    Physician Obtaining Signature* Time

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