Bariatric Surgery Anesthesia Consent Form

Patient Name:

Procedure

I understand that I will undergo bariatric surgery with anesthesia. The anesthesia planned has been explained to me and may include general anesthesia, regional anesthesia, local anesthesia, or monitored anesthesia care.

Risks and Complications

Anesthesia risks including, but not limited to: breathing difficulties, allergic reactions, nausea, vomiting, and rarely, heart or brain complications.
Awareness during anesthesia.
Dental, vocal cord, or airway injury.
Other risks unique to my medical conditions and history.

Patient Acknowledgement

I have had the chance to ask questions about anesthesia and my questions have been answered.
I understand the potential risks and benefits of anesthesia for bariatric surgery.
I understand that my anesthesia care will be provided by a qualified provider.
I consent to the administration of anesthesia as described above.

Contact in Case of Emergency

Name:

Phone:

Patient Signature

Date:

Witness Signature

Date:

Anesthesia Provider Signature

Date: