anesthesia consent

I, <Patient Name>, have been scheduled for an Upper GI endoscopy. I understand that anesthesia
services are needed to help the physician perform the procedure.
It has been explained to me that all forms of anesthesia involve some risks and no guarantees can be
made concerning the outcome. Although rare, unexpected complications can occur with each type of
anesthesia, including the possibility of adverse drug reaction, minor pain and discomfort, respiratory
problems, low blood sugar and or heart rate, unconscious state, injury to blood vessels and
surrounding tissue, headache, heart attack/stroke, aspiration, dental injury, and that additional specific
risks have been identified below as they may apply to a specific type of anesthesia.
I understand that there are two options/types of anesthesia that can be used for this procedure.
DEEP SEDATION (Monitored Anesthesia Care)
Definition: Drug induced depression of consciousness during which patients cannot be easily aroused
but respond purposefully repeat stimulation. This type of anesthesia can allow for better visualization
of the colon in addition, patient satisfaction is higher with less nausea.
Side Effects: Pain on injection and mild muscle movements are common but non harmful.
Risks: Include but not limited to depressed breathing, unconscious state, aspiration.
CONSCIOUS SEDATION (Light to Moderate)
Definition: An altered state of consciousness that minimizes pain, discomfort, and anxiety through the
use of pain relievers and sedatives. Patients who receive this type of anesthesia are usually able to
speak and respond to verbal cues communicating any discomfort to the provider.
Side Effects: Patients may have nausea, vomiting, headaches, and amnesia. It takes an average of 24-48
hours to recover and for the first 24 hours we ask that you do not drive a vehicle, make critical
decisions, or engage in tasks that require a high level of concentration, or fine motor skills.
Risks: Include but not limited to depressed breathing, vomiting, and aspiration.
Women and Pregnancy: Pregnancy testing is offered to females of child bearing age. Anesthesia has
been associated with birth defects and miscarriage. If there is any possibility that you are pregnant it is
advisable to postpone an elective procedure.
I acknowledge I have read this informed consent or had it read to me. I understand the risks,
alternative and expected results of anesthesia services. I have had my questions answered and
agree to treatment.
< Patient Signature>
< Anesthesia Provider Signature >