Hospitals & healthcare
Anaesthesia consent template
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Anaesthesia Consent
Date: Date
I, Patient Name, file no. File Number, consent to Anaesthesia Type for Procedure Name, after the anaesthetist, Dr. Anaesthetist Name, explained the method and its risks. I have followed the fasting instructions, which are Fasting Instructions.
The nature of the procedure, its expected benefits, its risks and possible complications, the alternatives and the consequences of not having it have been explained to me; I was able to ask questions, and I know I may refuse it or withdraw my consent before it starts.
Patient: Patient Signature
Anaesthetist: Anaesthetist Signature
Witness: Witness Name – Signature: Witness Signature
Date and time: Date – Time