A 醫療財團法人辜公亮基金會和信治癌中心醫院 KOO FOUNDATION SUN YAT-SEN CANCER CENTER Informed Consent for Postoperative Pain Management Name: Date of Birth: Gender: Personal ID: Patient ID: Types of Postoperative Analgesia (Price schedule) □ □ □ □ □ Patient Controlled Analgesia(NT$ 6000) Epidural Analgesia(NT$ 8000) Thoracic Paravertebral Block (NT$ 4500) Transversus-Abdominis Plane Block(NT$ 2000) Others: (NT$ ) Physician Statement : 1. I have evaluated and explained to the patient on his/her options regarding postoperative pain management. 2. I have discussed with the patient on details concerning postoperative analgesia, particularly on 1) the procedure, 2) risks and complications, 3) possibility of technical failure/difficulty and conversion to other method and, 4) the cost. 3. I have provided educational brochure on the selected postoperative pain management. 4. I have answered questions concerning the postoperative analgesia. Patient Statement : 1. I understand the importance of postoperative analgesia on the quality of postoperative recovery and medical care and I consent to the recommended postoperative pain management. I believe that the staff at the KFSYSCC will be vigilant about the medical care to minimize the risks of possible complications. 2. I have been explained by the anesthesiologist on the cost and method of postoperative analgesia and its related risks. Should any complications occur, I understand that the medical staff at the KFSYSCC will take whatever medical actions necessary to the best of their knowledge. 3. I fully understand the content of the selected postoperative pain management. 4. I understand I am free to choose my preferred method. My questions concerning the postoperative analgesia have been answered by the anesthesiologist to my satisfaction. PATIENT/OTHER LEGALLY RESPONSIBLE PERSON Name (print and sign) : Relationship to patient: Phone number: Witnessed by (print name and sign): Address: Anesthesiologist Signature: Time: mm/ ________ Tel #: Time: mm/ (1430/1206) dd/ dd/ yy yy M09-03-02-1