Obstetric Epidural Anesthesia Consent Form

Patient Information

Patient Name: Date of Birth: Medical Record Number:

Procedure Description

Risks and Benefits Explained

Alternative Options

I understand that:

The nature and purpose of the epidural have been explained to me. The risks and possible complications have been discussed with me. I have had the opportunity to ask questions and understand alternative forms of pain relief.

Comments or Additional Information

Consent

I hereby authorize the use of epidural anesthesia during my labor and delivery. I acknowledge that I have read and fully understand the above information.

Patient Signature:

Date:

Witness Signature:

Date:

Anesthesiologist Signature:

Date: