Cardiac Surgery Anesthesia Consent Form

Patient Name: Date of Birth:

Medical Record Number: Date:

Procedure

Name of Procedure:

Indication/Reason:

Anesthesia Information

I have been informed about the type of anesthesia planned, its purpose, benefits, risks, and alternatives including no anesthesia.

Anesthesia Type: Risks/Complications Explained: Alternatives Discussed:

Consent

I have read and understand the information above. My questions and concerns have been addressed. I voluntarily consent to anesthesia for my cardiac surgery procedure.

Patient/Legal Guardian Signature Date:

Witness Signature Date:

Anesthesia Provider Signature Date: