Emergency Surgery Anesthesia Consent Form

Patient Name

Date of Birth

Medical Record Number

Date

Emergency Surgery Details

Type of Surgery Diagnosis / Reason for Surgery

Anesthesia Information

Type of Anesthesia Proposed Risks, Benefits, and Alternatives (explained by physician)

Consent Statement

I acknowledge that the nature, risks, and purpose of the anesthesia for my emergency surgery have been explained to me. All questions have been answered to my satisfaction. I voluntarily consent to the administration of anesthesia and related procedures as described above.

Patient or Legal Representative Signature

Date

Physician/Anesthesiologist Signature

Date