Hopital Name:
Doctor-in-charge / Principal Surgeon / Principal Interventionist:
Dr.
Qualification:
Address:
Phone:
Email:
 Consent For Anaesthesia

Information about the patient:
Name: Mr./Ms./Mrs.
Age: Years
Address:

Information about the patient’s guardian (proxy consent) :
(This clause should be filled and the guardian should sign this consent only in case of incompetent patients i.e. minors, old aged, unconscious, mentally unfit, disoriented patients)
Name: Mr./Ms./Mrs.
Address:
Phone no.
Relationship with the patient, if any:
[A person accompanying an unrelated patient should write ‘Unrelated-accompanying’ and when consent is given by higher authorities of a hospital, designation such as ‘Medical Superintendent’ or ‘Medical Director’ must be written.]

Scheduled date for the proposed intervention / procedure / surgery:

Principal Anesthetist:

Name: Dr.
Qualification:

Type/s of anesthesia proposed to be induced:

a.
b.

I, the undersigned, do hereby state and confirm as follows:
1. I have been explained the following in terms and language that I understand. I have been explained the following in ……. (name of the language or dialect) that is spoken and understood by me.
2. I have been explained; I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named principal anesthetist and his / her team with associates or assistants of his / her choice to induce anesthesia mentioned hereinabove during the course of the proposed intervention / procedure / surgery and also to administer the requisite drugs and medications.
3. I have been explained and have understood the importance of preoperative fasting and the risks of consuming solids / liquids prior to the induction of anesthesia.
4. I have been explained and have understood that inducing anesthesia has certain material risks / complications and I have been provided with the requisite information about the same. I have also been explained and have understood that there are other undefined, unanticipated, unexplainable risks / complications that may occur during or after inducing anesthesia.  
5. I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.  
6. I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.  

Date & Time of giving consent:
Patient’s / Guardian’s Signature / Thumb impression:
Patient’s / Guardian’s Name: