Outpatient Procedure Anesthesia Consent Form

Patient Name Date of Birth Procedure Physician Anesthesia Provider

Consent Information

I understand that anesthesia is necessary for my outpatient procedure. The risks, benefits, and alternatives have been explained to me. I have had the opportunity to ask questions about the anesthesia, and these questions have been answered to my satisfaction.

Patient's Acknowledgement / Additional Notes

Patient/Representative Signature Date

Witness (if required) Date

Provider Signature Date