NORTH TEXAS ANESTHESIA SAMPLE INFORMED CONSENT

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

I voluntarily request my physician and his assistants to treat my condition. I understand that my physician may discover other or different conditions which require additional or different procedures than those planned. I authorize my physician and assistants to perform such other procedures which are advisable in their professional judgment.

I do__ do not__ consent to the use of blood and blood products as deemed necessary. I also realize that the following risks and hazards may occur in connection with this particular procedure: fever, transfusion reaction which may include kidney failure or anemia, heart failure, hepatitis, AIDS, among other infections.

I understand that no warranty or guarantee has been made to me as to result or cure.

I understand that anesthesia involves additional risks and hazards, but I request the use of anesthetics for the relief and protection from pain. I realize the anesthesia may have to be changed, possibly without explanation to me.

I understand that certain complications may result from the use of any anesthetic including, but not limited to, respiratory problems, drug reactions, paralysis, brain damage or even death. Other risks and hazards which may result from the use of general anesthetics range from minor discomfort to injury to vocal cords, teeth, or eyes. I understand that risks and hazards resulting from spinal or epidural anesthetics can include headache and chronic pain. I understand that peripheral nerve blocks may cause temporary or permanent damage to specific nerves.