ANESTHESIA / CONSENT

I, the doctor of anesthesia, stated that I explained the following correctly and clearly and had given the opportunity to the
patient / family to ask.
type of information Information provided
1. diagnosis
2. operation action
3. anesthesia  anesthesia  local  spinal
4. indication of action
5. procedures

6. purpose
7. risk
8. complications
9. prognosis
10. alternative & risk

I, the undersigned below :

Name :…………………………………(M / F )* Date of birth / age :…….............th
No. KTP / SIM /PASPOR :…………………………………
…………………………………telephone : ………………………….............
Relationship with patient’s :  self  husband  wife child  Parents

Hereby declares the fullest, that I have received the information provided bye the doctor as above
understand it. For that I give CONSENT to carry out the act of ANESTHESIA of:

Name :……………………………………(M / F)*Date of birth / age :……………..th

No. MR :…………………………………………………………………………………..
Address :……………………………………telephone :………………………….............

I understand the need and benefits of such actions including the risks and complications that will arise. I
also realize that medical science is not an exact science, so the success of medical action is not a
necessity, but depends on the permission of God who is almighty.

Denpasar,……………o’clock :……………
Anesthetist Hospital witness Patient witness That states
Name
Signature