Consent for Anesthesia
I have requested an anesthetic for my surgery with Dr. David Rankin at Aqua Plastic Surgery. I understand that there are risks and possible complications anytime an anesthetic is given. I have received this information about the possible risks and complications due to anesthesia.
1. I understand the most common risks of anesthesia include allergic reactions to medications used, discomfort, bruising, or swelling at the site of any injection or IV, irritation of the vein where the IV was placed causing possible phlebitis, which could adversely affect the arm and require surgery or therapy, nausea or vomiting, which may require intervention with fluid or medications.
2. I understand that anesthesia is a serious medical procedure and carries with it a risk of nerve injury, brain damage, heart attack, death, pulmonary embolus, and other risks that may occur less frequently from either known or unknown causes.
3. I understand that anesthetic may cause prolonged drowsiness and that I should not drive an automobile, operate machinery, or make legal or important decisions within 24 hours of an anesthetic.
4. I understand that I must not eat or drink anything, other than medications as directed, within 8 hours before the anesthetic; to do otherwise may be life threatening and will require the procedure to be re-scheduled.
5. I understand the type(s) of anesthesia checked below will be used for my procedure. The anesthesia technique is determined by many factors including my physical condition, the type of procedure, my doctor’s preferences, as well as my own desire. It has been explained to me that sometimes an anesthesia technique which involves the use of local anesthetics, with or without sedations, may not succeed completely, and therefore another technique may have to be used including general anesthesia.
__X__ General Anesthesia: A medication is administered through my vein and through the air that I breathe which will make me unconscious. A tube may be placed into my windpipe to ensure proper airway and my breathing will be assisted.
__X__ Deep IV Sedation: A medication is administered through my vein. I will be asleep and not easily aroused. I may require some assistance breathing.
____ Conscious Sedation: A medication is administered through my vein to reduce anxiety. I will be breathing on my own and will respond to verbal command and touch.
6. I understand that teeth or dental prosthetics may become loose, broken, or dislodged, especially if loose or in poor repair regardless of the care provided by the anesthesia personnel. By signing this consent you are acknowledging that neither your anesthesia provider, New Creation Anesthesia, Aqua Plastic Surgery, or the surgeon, will be liable for any dental damage or repairs.
By signing this consent, I state that I am at least 18 years of age, I have read and understand this consent form, and give my consent as described in this form. This office is regulated pursuant to the rules of the Board of Medicine as set forth in Rule Chapter 64B8, F.A.C. A choice of anesthesia provider exists as set forth in rule 64B8-30.012 (2) 9b06. F.A.C.
Anesthetist Signature: ______________ Date: ___________________