Cosmetic Surgery Anesthesia Consent Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Procedure Information
Procedure Name
Scheduled Date
Surgeon's Name
Anesthesia Information
Local Anesthesia
Regional Anesthesia
General Anesthesia
Sedation
Medical History
Allergies
Current Medications
Medical Conditions
Consent and Acknowledgement
I have been informed about the nature and purpose of the anesthesia and procedure.
I understand the risks, benefits, and alternatives.
I have had the opportunity to ask questions.
I consent to receive the designated anesthesia.
Patient / Guardian Signature
Date