Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Anesthesia Consent Form
Full Name *
Anesthesia Type Explanation
Anesthesia Risk Acknowledgment
Previous Anesthesia Reactions
Malignant Hyperthermia History
NPO/Fasting Instructions Acknowledged
Pre-Anesthesia Health Screening
Date of Birth
____ / ____ / ________
Date of Consent
____ / ____ / ________
Patient Signature
Date
Anesthesia Consent Form template from formisoft.com. formisoft.com/intake-templates/anesthesia-consent