40» Race Plalno{Consultant Name) here by authorize the performance of the following operations(s) procedure(s), treatment(s) Upon... views Vea Iconsenttothe administration of anaesthesia, | Wwe) understand that all forms of anaesthesia involve additional risks and hazards, but | (we) request the use of anaesthetics for the relief and protection form pain during the planned and additional procedures. (we) realize that anaesthesia may have tobe changed possibly without explanations tome, when needed. CONSENT FORM FOR ANAESTHESIA eRe a RO Cu oC Plies “(Name ofthe patient) --anaesthesia 4 General anaesthesia Includes intravenous ‘agents and / or inhaled gases Expected Result Total unconscious state, possible placement of a tube into the trachea (windpipe) Technique Drug injected into the bloodstream and / or breathed into the lungs and / or by other routes. Risks (Include but not limited to) ‘Mouth or throat pain, hoarseness, injury to mouth or teeth, voical cord injuries, awareness under anaesthesia, injury to blood vessels, vomiting, aspiration, pneumonia je Spinal or Epidural Analgesia Anaesthesia Includes needle injection into subarachnoid space Expected Result ‘Temporary decreased or loss of feeling and / or movement to tower part of the body, variable degrees of awareness. Technique Drug injected through a needle / catheter placed either directly into the fluid ofthe spinal canal or immediately outside the spinal canal. Risks (Include but not limited to) Headache, backche, buzzing in the ears, convulsions, infection, persistent weakness, pruritus, numbers, residual pain, injury to blood vessels, “total spinal” Nerve Blocks Includes Needle Injections near major or minor nerves Expected Result ‘Temporary loss of feeling and / or movement of a specific limb or area, variable degrees or awareness. Technique Drug injected near nerves providing loss of sensation to the area of operation, Risks (Include but not limited to) Infection, convulsions, weakness, persistent numbness, residual pain requiring additional anaesthesia, injury to blood vessels, lungs, failed look, pneumothorax. + Intravenous Regional Anaesthesia Expected Result "Temporary loss of feeling and / or movement of a limb variable degrees of awareness. Technique Drug injected to veins of arm or leg while using a tourniquet, Risks (Include but Not limited to) Injection, convulsion, persistent numbness, residual pain, injury to blood vessels. ‘+ Monitored Anaesthesia Care Includes local anaesthetics with or without intravenous sedatives Expected Result Reduce anxiety and pain, partial or total amnesia, variable degrees of awareness. Technique Drug injected into the blood stream, breathed into the lungs, or by other routes, producing a semi-conscious state, Risks (Include but not limited to) ‘An unconscious state, depresses breathing, injury to blood vessels.| understand that the type of Anaesthesia service provided for the desired operation, procedure, treatment Is, determinded by many factors including my physical condition, the type of procedure my doctor is going do as well as my ‘own desire. | also understand that my physical condition as well as the type and length of surgery wil influence the Intraopeartive course and outcome following anaesthesia. The need for ICU care and ventilatory support in the post ‘operative period. Should theneed arise had also been impresed upon me and | give the consent forthe same. Anesthetic ‘management for the surgery requires intravascular cannulation and use of various monitors that may result in complications associated with them, The likelihood of success of the intended anaesthetic technique is possible / probable good outcome likely failure. ‘Thereby consent to the Anesthesia service checked above and authorize that it be administrered by Anesthesiologist all of whom are credentialed to provide anaesthesia services at Rainbow Hospital. "also concent to an alternative type of Anaesthesia, if necessary, as deemed appropriate by the Anesthesiologist at this facility. | certify and acknowledge that | have read this form or had it read to me, explained to me in my mother tongue and | understand there are risks, altematives and expected results of Anaesthesia service. | had ample time to ask Questions and to consider my options before making the final decision. er | have been explained about the various options available for post operative analgesia and | hereby also consent for ‘multimodal pain management post operatively. ‘a Q y Patient Name: MIP :Q9R/D Ey) ‘Sign. Ay Date peor Wines: MMe yneuvenrt) wane son_/Duvty Date_lo| 12 22@ 19] Doctor:_ OP -ARL NSuBHp4 Sign, h oe -ARUN SUBH, PATIENTREPRESENTATIVEISURROGATE DFS. Reo. Nor aeagternnen) The patient is unable to give consent because: and I —— (name/relationship to the patient), therefore consent for the Patient | acknowledge that | have had an opportunity to discuss and understand this procedure, as stated above, with my Physician or physician designee, and hereby consent to this procedure. “1 io PatientNam« = Sign, = Date. Witness = Sign, = Date. Doctor: = Sign, = Date REVIEW OF CONSENT, IN CASE OF POSTPONEMENT Patient /Guardian Name _— eas Sign, = Date, Witness = Sign, = Date, Dostor: Sign, Date. Date telialrs-@pgoperDT MU tsa me gael N Rainbow Hospitl Cone mom Noo MG ou) ipreir . OE sgiauier Oui) Bsoir eps Veiraugib oswedrunGscit, Osudepeopssr Screg, ABéore eo wuss wessiagsen &p. hs Cromunefusen Susuwi)... ComIUGeS opus SiSenmb Sah &per DUES Wes! eilugdS pret abdGSApein. atdoor sunsuiner DUES UGEBEE saBso Spusgeseoui, SumuTiiseenuy Leiter ssugs cteiuony pono (Enver) ykbgs Gesmsirsmmd. 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