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