Cancer Surgery Anesthesia Consent Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Procedure Details
Diagnosis
Scheduled Surgery
Surgery Date
Anesthesia Information
Type of Anesthesia
Risks and Possible Complications (to be explained by the doctor):
Patient/Guardian Consent
I have read and understood the information provided regarding anesthesia for my cancer surgery.
My questions about anesthesia risks, benefits, and alternatives have been answered.
I give my consent for anesthesia to be administered as described.
Patient/Guardian Signature
Date
Anesthesiologist Signature
Date