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(continuedfromreverse) 6.RISKSANDCOMPLICATIONSofanesthesiaincludebutarenotlimitedto:allergic/adversereaction, backache,bleeding,dentalinjury, headache,infection,localizedswellingorredness,muscleaches, nausea,eyeinjury,pain,pneumonia,positionalnerveinjury,recallofsound/noise/speech/sensationby othersandsorethroat. RARERISKSANDCOMPLICATIONSofanesthesiaincludebutarenotlimitedto:aspiration,inabilityto reverseeffectsofanesthesia,braindamage,coma,paralysis,seizures,anddeath. PROCEDURE: NAMEOF PATIENT: MyAttendingPhysicianisDr. MyPhysicianorSurgeonisDr . SIG N AT UR E: (PATIENT/PARENT/CONSERVAT OR/G UARDIAN) D ATE: TI M E: Rela t ionshipi fS ignedbyo t her t han P a t ien t: W i t ness : VERIFICATIONOFINFORMEDCONSENTFORSURGERY/PROCEDURE I.Surgeon/PhysicianStatementofInformedConsent Ihaveinformedthispatientoftherisks,benefits,potentialcomplications,andalternativetreatmentsfor thisprocedure.Ihaveansweredanyquestionsaskedandthepatient/guardianagreestotheprocedure. II.PaulGannBlood SafetyAct Isbloodtransfusionanticipated? No Y es Ifyes,thefollowingstatementapplies: Ihavediscussedthepossibilityoftransfusionandassociatedrisksandhaveansweredquestionsasked. Ihaveprovidedthispatient/guardianwithinformationconcerningtheadvantages,disadvantages,risks andbenefitsforautologousblooddonationandofdirectedandnondirecteddonationofbloodby volunteers.Ihaveprovidedthispatientacopyofthepamphlet“Ifyouneedblood...”providedbythe CaliforniaDepartmentofHealthServices.Ihavealsoprovidedadequatetimepriortosurgerytoallow predonationofbloodtooccurwiththefollowingexceptions:alife-threateningemergencyoccurred,there aremedicalcontraindications,orthepatientwaivedthisright. III. Ihaveverballyverifiedwiththepatient,family/designatedrepresentativeorguardianthecorrectsiteforsurgery. MDSignature (Surgeon/Physicianperformingprocedure) PrintNameandDictation#DateTime VERIFICATIONOFINFORMEDCONSENTFORANESTHESIA Ifanesthesiaisrequired,completethefollowing: IV.AnesthesiologistStatementofInformedConsent Ihavediscussedtherisks,benefits,andcomplicationsofanesthesiawiththispatient.Ihavealso discussed the rare complications of anesthesia. Ihave answered any questions asked and the patient/guardianagreestotheuseofanesthesia. V. Ihaveverballyverifiedwiththepatient,family/designatedrepresentativeorguardianthecorrectsiteforsurgery. MDSignature (Anesthesiologist/Physicianperforminganesthesia) PrintNameandDictation# DateTime AUTHORIZATIONFORANDCONSENT TO SURGERY ORSPECIALDIAGNOSTICOR THERAPEUTICPROCEDURES 856000006REV.(07/12) WHITE -CHART YELLOW -PATIENT PATIENTIDENTIFICATION NPS 800.660.1988 GENCN
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