MEDICAL HISTORY FOR PEDIATRICS
CONSENT FOR ANESTHESIA SERVICES
The following is provided to inform patients about having treatment under anesthesia. The information is not presented to make you more apprehensive, but rather to enable you to better understand the risks and benefits involved with anesthetic treatments.
I, the undersigned, hereby authorize and request any doctor represented with CarePoint to administer anesthesia as previously discussed with me. I understand and agree that procedures not talked about, but deemed necessary for my child’s well-being may be performed to supplement the planned anesthesia. It has been explained to me that all types of anesthesia, although safe, involve some risks and no guarantees can be made concerning results. Serious complications are very rare. The following are complications that may be associated with the anesthetic treatment:
I consent to the anesthesia deemed appropriate by my anesthesiologist. I acknowledge that I have read this form or had it read to me and that I understand the risks, alternatives, and expected results of the anesthetic plan of care.