BETH ISRAEL MEDICAL CENTER

*1111* 1111

CONSENT FOR ANESTHESIA

IN THE OPERATING ROOM

1. Types of Anesthesia: There are several ways to administer anesthesia in the operating room - the anesthetic choice
is related to your general condition and medical history as well as the surgery or procedure being done. General
Anesthesia uses medicines to put you in a deep sleep, and gases to keep you asleep. With this technique, we will
often use medicines to relax muscles and techniques that support your breathing. Regional Anesthesia (nerve blocks,
epidural, spinal, etc.) means injection of medicine through a small needle to “numb” specific areas of the body. Local
Anesthesia can provide loss of pain sensation over the areas where surgery is performed and may be combined
with sedation to induce a light sleep. Monitored Anesthesia consists of local injections as well as the use of
medications to make you drowsy. You will be able to communicate with the staff during this type of anesthesia.

I hereby request and authorize Dr. _________________________________________ and/or associates of his/her

choice at Beth Israel Medical Center to provide to me or the named patient the following type(s) of anesthesia:

M General Anesthesia M Local Anesthesia

M Regional Anesthesia M Monitored Anesthesia
M Nerve Block M No Anesthesia
M Epidural
M Spinal

Procedure: __________________________________________________________________________________

___________________________________________________________________________________________

Site (if applicable): M Left M Right

2. I understand that the probability of significant harm from anesthesia is minimal. Occasionally, anesthesia may be
associated with the occurrence of nausea, vomiting, dizziness, drowsiness, headache, depression, numbness, dental
damage, sore throat, urinary retention and changes in smell and taste for a brief time. Some potential risks which
are less likely to occur include, but are not limited to, infection; breathing problems; unexpected reaction to drugs;
serious rapid increase in body temperature; failure to recover from anesthesia, including death.

3. I understand that the medications I am taking may cause complications with anesthesia and surgery. I have informed
my anesthesiologist about these medications, as well as any herbal/over-the-counter/nutritional supplements and/or
any recreational/”street” drugs.

4. The effects of anesthesia on the fetus during early pregnancy are not completely understood, so I have informed my
anesthesiologist if there is any possibility that I could be pregnant.

5. I understand that equipment may be used to assist my breathing. It is also possible that it may be necessary to insert
catheters or other devices to monitor my bodily functions during anesthesia.

6. Blood/Blood transfusion requirements:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

7. The undersigned anesthesiologist and/or associate(s) has fully explained to me the nature of these anesthetics, the
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way they are given, alternative anesthetics, the activities performed in connection with anesthesia, the anticipated
anesthetic plan for my surgery or procedure and the possible risks and complications. I have been given the
opportunity to ask questions, and all my questions have been answered to my satisfaction.