醫療財團法人辜公亮基金會和信治癌中心醫院
Name：
KOO FOUNDATION SUN YAT-SEN CANCER CENTER
Date of Birth：
Informed Consent for Anesthesia
Personal ID：
1 Diagnosis
Gender：
Patient ID：
：__
2 Proposed Surgery：__
3 Proposed Anesthesia Plan
□ General anesthesia (intubation or laryngeal mask)
□
□
□
Intrathecal / Epidural anesthesia
Intravenous general anesthesia
Regional anesthesia
4 Failure or difficulty in administering the intrathecal/epidural anesthesia could result in
conversion to general anesthesia in some cases.
5 For better perioperative care and patient safety, the anesthesiologist may opt for different
medical equipments that are invasive, with possible risks involved in the placement of
invasive monitors and catheters, which include: central venous catheter, nasogastric tube,
foley, intra-arterial line, pulmonary artery catheter, endotracheal tube, epidural catheter,
ultrasound guided local injection and etc.
Physician Statement
1 Having done the pre-op evaluation, I provided details on the methods of anesthesia to the patient.
2 I have explained to the patient in the language he/she understands, on details concerning the
anesthesia, particularly on 1) the steps, 2) risks and complications, 3) postoperative side
effects and care, and 4) different options.
3 I have provided educational brochure on the selected anesthesia method.
4 Patient has been given ample time to ask any questions that he/she may have concerning the
anesthesia procedure. For this patient, the ASA class is ______ for this surgery.
Patient Declaration
1 I understand that in order to have a successful surgery, anesthesia is required. I believe the
anesthetic staff at the KFSYSCC will be vigilant about my perioperative care to minimize
the risks of complications.
2 I have been explained by the anesthesiologist on the methods of anesthesia, steps and
associated risks. Should any complication or emergency occur perioperatively or
postoperatively, I consent to the medical judgment and resuscitation efforts performed by
the medical staff at the KFSYSCC.
3 I understand the content in the anesthesia manual and health education guide.
4 My questions concerning the anesthesia have been answered by the anesthesiologist.
5 By signing below, I consent to anesthesia in accordance with the above statements.
PATIENT/OTHER LEGALLY RESPONSIBLE PERSON
Name (print and sign) :
Relationship to patient：
Phone number：
Time：
mm/
dd/
yy
Witnessed by (print name and sign):
Address：
Time：
mm/
dd/
yy
Anesthesiologist Signature：
Time：
mm/
dd/
yy
(1430/1206)
________
Tel #：
M09-03-01-3