麻醉同意書
Wanciao Veterans Hospital ,VAC, Executive Yuan
CONSENT TO ANESTHESIA
Date : ____________
Medical Chart #:
To: Wanciao Veterans Hospital, VAC, Executive Yuan
________________, the Patient, Gender __, born on ___________, has suffered from the disease of
________________, which requires surgical operation of _____________. For the disease, Dr.
________________ of Wanciao Veterans Hospital (who signs in person hereunder) has explained
to me in person the following facts. I , ________________, the Undersigned, hereby confirm my
full understanding of such facts and further confirm consent to the surgical operation oriented
anesthesia Wan-Ciao Veterans Hospital conducts on the Patient:
I.
The method of anesthesia and anesthetic surveillance.
II.
The complications and risks possibly resulting from the anesthesia (Cf. Explanations on
Anesthesia provided on the reverse page).
In the process of the surgical operation oriented anesthesia, Wanciao Veterans Hospital is
supposed to exercise due diligence in medical treatment as required. In case of an emergency
taking place during the process of surgical operation oriented anesthesia or anesthesia
convalescence, I agree to accept all emergency treatment which Wanciao Veterans General
Hospital considers necessary.
Consented by:
___________________ (Signed with seal)
ID No.
:
___________________
Address
:
______________________________________
Telephone
:
______________________________________
Relationship with the Patient: ___________________
Remarks:
I.
This Consent is signed by the Patient in person. Where the Patient is a minor or unable to sign in person, the
Consent may be signed by a relevant person as defined by Article 46, Paragraph 1 of the Medical Treatment Law.
II. Where the Consent is signed by a person other than the Patient, the relationship with the Patient shall be entered
in the space of “Relationship with the Patient”.
III. In the event that another surgical operation is required after the patient receives the surgical operation, the surgical
operation shall not be conducted until another consent is duly signed in accordance with the procedures herein
except an emergency defined under Article 46, Paragraph 1 of the Medical Treatment Law.
IV. Article 46, Paragraph 1 of Medical Treatment Law provides: “The hospital shall obtain the consent from the
patient or the patient’s spouse, relative or a related person who shall sign Consent to Surgical Operation and
Consent to Anesthesia before the surgical operation is conducted. Until the Consents are signed, the doctor shall
explain to the patient, or the patient’s spouse, relative or a related person, the reasons why the patient should
receive the surgical operation, the changes of success, and the possible complication(s) and risks of the surgical
operation.
麻醉說明書
EXPLANATIONS ON ANESTHESIA
I. As far as the Patient’s disease is concerned, surgical operation is indispensable.
For the surgical operation, anesthesia is equally indispensable. Other than the
effect to help surgical operation, anesthesia will help the Patient be free from the
pain and fear during the surgical operation. For Patients who receive anesthesia,
either general or local anesthesia, nevertheless, the following side effects and
complications are possible:
(I)
A patient with existent or potential cardiovascular disease is more likely to
be subject to abrupt acute myocardial infarction during surgical operation or
after anesthesia.
(II) A patient with existent or potential cardiovascular system or cerebral
system disease is more likely to be subject to cerebral apoplexy during
surgical operation or after anesthesia.
(III) In case of emergency surgical operation or untold eating, anesthesia is
likely to result in malignant fever (This is a sort of potential hereditary
disease for which a test beforehand is impossible as far as the medical
science today is concerned.)
(IV) Abrupt response resulting from extraordinary drug allergy or blood
transfusion.
(V) Brief or prolonged damage to nerves possibly resulting from local
anesthesia.
(VI) Other adventitious diseases.
II. The Patient or the person who signs the consent is required to consult with the
doctor in detail about the question(s) regarding what is explained above, if any,
before signing the consent.