7905095365, 8604955736

SAREEN’S ENT
Name of Patient...................................................................

Age/Sex....................Room/Ward No..................................
& HEAD NECK CEBTRE UHID. No................................IPD No...................................
cee@ue kesâ heerÚs, yeer-1, Sme.kesâ. ieghlee keâeueesveer
(Ûevõe DeeF& kesâÙej kesâ yeieue ceW) uebkeâe, JeejeCemeer Consultant.........................................D.O.A.........................

INFORMED CONSENT FOR ADMINISTRATION OF ANAESTHESIA

Proposed Surgery/ efÛeefkeâlmee : .................................................................

 7905095365, 8604955736

SAREEN’S ENT
& HEAD NECK CEBTRE
cee@ue kesâ heerÚs, yeer-1, Sme.kesâ. ieghlee keâeueesveer
(Ûevõe DeeF& kesâÙej kesâ yeieue ceW) uebkeâe, JeejeCemeer
Aneesthesiologist Signature (Min.One) I have carefully reviewed the Pre-Anesthetie Assessment and Laboratory Investigations.
1 I have examined the patient and clearance is given to proceed with Anesthetic card.
2
3 Pre-Induction : ( h) BP HR

N20/ 02 / Air LPM

Agent ET%
TIME :
TOF :

Temp 1N/O/R/S

Temp 2N/O/R/S 200

190
HR
180
NIBP / Art Press :170
160
LA/RA/ LL / RL
150
V Systollc 140
130
x Mean
120
V Diastolic 110
100
90
80
70
60
50
40
30
20

EVENTS -

FiO2

SpO2

PECO2

Alrway Press

Reep Rate

Tidel Vol.

Toumlquet

IV Flulds (1) ml

IV Fluids (2) ml

Blood ml

Blood Lose ml

Urine Output ml

Anes Start Surgery Start @ Surgery End @ Anes End