Informed Mid South Anesthesia Consent for Sedation Please complete this Mid South Anesthesia Consent for Sedation form below. If you have any questions call us on (615) 915-6090. HiddenVersion historyv1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : 1st version, 2020-06-05 (add)Patient name:* First Last Patient date of birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Consent for Anesthesia ServicesI acknowledge that my doctor has explained to me that I will have an operation, diagnostic or treatment procedure. My doctor has explained the risks of the procedure, advised me of alternative treatments and told me about the expected outcome and what could happen if my condition remains untreated. I also understand that anesthesia services are needed so that my doctor can perform the operation or procedure. It has been explained to me that all forms of anesthesia involve some risks and no guarantees or promises can be made concerning the results of my procedure or treatment. Although rare, unexpected severe complications with anesthesia can occur and include the remote possibility of infection, bleeding, drug reactions, blood clots, loss of sensation, loss of limb function, paralysis, stroke, brain damage, heart attack or death. I understand that these risks apply to all forms of anesthesia and that additional or specific risks may apply to a specific type of anesthesia. I understand that the type of anesthesia used for my procedure and that the anesthetic technique to be used is determined by many factors including my physical condition, the type of procedure my doctor is to do, his or her preference, 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 sedation and/or general anesthesia, may not succeed completely. I hereby consent to the anesthesia care and authorize that it be administered by Anesthesia Provider(s) of Mid South Anesthesia, PC all of whom are credentialed to provide anesthesia services at this health facility. I also consent to an alternative type of anesthesia, if necessary, as deemed appropriate by them. I certify and acknowledge that I have read this form or had it read to me, that I understand the risks, alternatives and expected results of the anesthesia service andthat I had ample time to ask questions and to consider my decision. SubmitName of Legal Guardian or Authorized Representative:* If not applicable use 'self'Today's date:* MM slash DD slash YYYY Do you wish to receive a copy of this Consent?* Yes No E-mail address:* Please sign*Important: You consent to sign this document electronically.
