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 Sit e____________ 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 pos t -operative pain control are strictly for my comfort and thus optional. I f I choose not to have the block, the result of surgery will not change and other alternative s 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 Physician/LIP Signature PID Number

*1-28001* FORM 1-28001 REV. 09/2013 Page 1 of 1