Pediatric Anesthesia Consent Form
Patient Name:
Date of Birth:
Parent/Guardian Name:
Procedure to be performed:
Anesthesia Information
Type of Anesthesia:
General
Regional
Local
Sedation
Provider:
Additional Information:
Consent & Acknowledgement
I acknowledge the procedure and anesthesia risks have been explained to me.
I consent to the use of anesthesia as indicated above for my child.
I have had the opportunity to ask questions.
Emergency Contact Information
Contact Name:
Relationship:
Phone Number:
Parent/Guardian Signature:
Date:
Witness Signature:
Date: