ANESTHESIA CONSENT

Confirmation of Informed Consent for Anesthesia

To the patient and/or guardian: this form is designed to confirm the discussion of and consent for proposed anesthesia to be administered for surgical, medical or therapeutic procedure.

An anesthesia professional will administer anesthesia appropriate to my condition and will monitor vital bodily functions during the procedure. I understand that anesthesia involves risks in addition to the procedure itself. These risks may include but are not limited to: adverse drug reaction, brain damage, nerve injury or death. Additionally: injury to teeth or dental work, damage to vocal cords, respiratory problems, minor pain and discomfort, damage to arteries and veins or headaches may occur. I am aware that in the administration of anesthesia other unexpected complications may occur. All of the above have been explained in terms I understand and my questions have been answered.

I certify that information given to me as a patient or guardian regarding history, problems, medications, food and fluid intake is correct.

I understand that a responsible adult must accompany every patient home when discharged from the Recovery Room. I understand that disregarding such advice could place one at risk if problems develop and go unreported.

I voluntarily authorize and consent to the administration of anesthesia.

Patient signature: ______________________Date and time: _______________

Witness  ________________________

Authorization for Release of Information and Assignment of Benefits

I authorize payment of medical benefits to Progressive Anesthesia and authorize the release of any medical records/information necessary to process claims. In addition, I understand that if Progressive Anesthesia is a participating provider with my insurance plan, that I am responsible for prompt payment of any co-payment/deductibles determined by the health insurance company.

Patient signature: _____________________Date and Time:_________________

HIPAA Notice:

Please note that Progressive Anesthesia and Summit Endoscopy Center are affiliated. As a result of this relationship Progressive Anesthesia may receive, use, obtain access or create protected health Information from or on behalf of Summit in the course of providing anesthesia service. In order to ensure your privacy and protection, please carefully read the HIPAA information which has been provided.