Geriatric Patient Anesthesia Consent Form

Patient Name:

Date of Birth:

Medical Record Number:

Procedure Information

Scheduled Procedure:

Date of Procedure:

Anesthesiologist:

Surgeon:

Type of Anesthesia

Planned Type(s) of Anesthesia:

Risks & Complications Explained

Summary of Common Risks and Complications:

Patient Medical History

Relevant Geriatric Conditions / Past Medical History:

Patient Acknowledgement

The potential risks, benefits, and alternatives of anesthesia have been explained to me. I have had the opportunity to ask questions, which have been answered to my satisfaction.

Patient / Legal Representative Signature

Date:

Witness Signature

Date:

Interpreter (if needed):

Interpreter Signature:

Date: