Ambulatory Surgery Anesthesia Consent Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Procedure Information
Surgical Procedure
Date of Surgery
Surgeon's Name
Anesthesia Details
Anesthesia Type
Anesthesiologist
Discussion and Risks
Risks, benefits, and alternatives discussed:
Consent
I have read and understand the above information and give my consent for anesthesia administration.
Patient/Representative Signature
Date
Witness Signature
Date
Comments/Notes