PLACE LABEL HERE
CONSENT FOR REGIONAL ANESTHESIA
American Anesthesiology Associates of Georgia
Do not sign this form before speaking with the anesthesiologist, reading, and understanding its contents.
PATIENT NAME: _______________________________
DATE: _______________________
TIME: _______________________
Anesthesia services have been requested in order for surgery to be performed. These services will be administered under the direction
of the anesthesiologist of American Anesthesiology Associates of Georgia, LLC.
The current informed consent law requires that you be informed of the material risks involved with regional anesthesia and peripheral
nerve blocks. Regional anesthesia and peripheral nerve blocks are used as primary anesthetic or for post-operative pain control.
When regional anesthesia and/or peripheral nerve blocks are used, you may experience: infection, nerve injury (temporary or
permanent), or a failed block requiring conversion to general anesthesia, allergic reaction, loss of function of any limb or organ,
paralysis or quadriplegia, brain damage, cardiac arrest or death. In addition to the above, in case of interscalene nerve block, puncture
of the lung is a possibility.
I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient’s medical
history, and other information in determining whether to perform the procedure or the course of treatment for the patient’s condition in
recommending the procedure which has been explained.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE
TO ME concerning the results of this procedure.
For a nerve block involving an extremity, please circle Right or Left then write out the Surgical Site____________Initial______
I understand that for safety reasons these blocks are performed while I am sedated, not asleep. Also, it may involve several
needle sticks to find the correct nerve. I understand that the blocks for post-operative pain control are strictly for my comfort
and thus optional. If I choose not to have the block, the result of surgery will not change and other alternatives for pain
control will be available to me. Furthermore, I understand that while the purpose of the block is to provide adequate pain
control for 12-24 hours after surgery, the block may fail and I will get only partial pain relief.
BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR EXPLAINED TO ME IN
GENERAL TERMS, THAT I FULLY UNDERSTAND ITS CONTENTS, THAT I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK
QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY. ALL BLANKS OR STATEMENTS
REQUIRING COMPLETION WERE FILLED IN AND ALL STATEMENTS I DO NOT APPROVE OF WERE STRICKEN BEFORE I
SIGNED THIS FORM. I ALSO HAVE RECEIVED ADDITIONAL INFORMATION, INCLUDING, BUT NOT LIMITED TO THE
MATERIALS LISTED BELOW, RELATED TO THE PROCEDURE DESCRIBED HEREIN.
I voluntarily consent to have the anesthesiologist perform the regional anesthesia or peripheral nerve block that is recommended for
me.
_________________________________
Signature of Person Giving Consent
________________________________
Relationship to Patient if not the Patient
Date: _____________________________
Patient unable to sign because: _________________________
Physician/LIP’s Statement:
I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed procedure, with the patient or the
patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask questions.
______________
Date
_____________
Time
*1-28001*
____________________________________
Physician/LIP Signature
FORM 1-28001 REV. 09/2013
_______________
PID Number
Page 1 of 1