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INFORMED CONSENT FORM – ANAESTHESIA
ADMINISTRATION
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PATIENT’S
NAME
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UID
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Gender
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Age
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WARD / BED NO.
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S. N.
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DESCRIPTION
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1.
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I
here by authorize Dr……………………………………………………………………………….. for administration of
anaesthesia on myself/my patient ………………………………………. ………………………………..(name of
patient). I have been explained and I permit performance of the suitable
anaesthesia technique on me for conduction of surgical procedure
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2.
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One
of the following anaesthesia technique will be used on me
1.
General
Anaesthesia
– Through inhaled anaesthetic agent and/or Intravenous use of anaesthetic medication.
This will cause unconsciousness, muscle relaxation and analgesia. The un-consciousness
reverses after withdrawal of anaesthetic agent
2.
Deep Sedation – This leads
to sedation and analgesia and is achieved through intravenous and inhaled
agents
3.
Regional anaesthesia – This can be
done through spinal, epidural or caudal nerve block. The process causes
temporary loss of sensation and pain in certain areas of body
I understand
that in case deep sedation or regional anaesthesia is not satisfactory,
general anaesthesia may be used.
I
understand that during my operation if condition requires change in course of
action, my anaesthesia provider will act on my behalf for my benefit and
safety.
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3.
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I understand
that Anaesthesia administration is associated with various risks up-to death
of patient. While my anaesthesiologist will take all professional care, no
guarantee can be made for outcome of anaesthesia.
Common side
effects associated with Anaesthesia include (but not limited to), nausea and vomiting, adverse drug reaction,
bronchospasm, laryngospasm, arrhythmias, dreams or recall of intraoperative
events, corneal abrasions, and damage to mouth, teeth, or vocal cord,
backache. Post-dural puncture spinal headache, massive block, neurological
injury (Caudia equine syndrome, numbness, pain or paralysis, epidural or
spinal haematoma, meningitis, damage to arteries, veins and in rare cases
permanent brain damage, heart attack, stroke, or death
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4.
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I also acknowledge that I have truthfully
disclosed, to the best of my knowledge, all medical history and condition,
asked to me.
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Signature and
name of the person giving consent
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Date / Time
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Relationship
with the patient
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Signature and
name of the witness
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Date / Time
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Signature and name of the doctor taking
consent
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Date / Time
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