| Dr (attending physician) .................................................................................................................................................. |
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| that for the scheduled surgical procedure described below: ..................................................................................... |
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| And once having assessed the patient´s medical history and the results of the preoperative tests performed (blood work, electrocardiogram, etc., it has been deemed necessary to administer anaesthesia. |
1. . GENERAL RISKS
As in any surgical procedure where anaesthesia is required, some risks and complications might occur during the anaesthetic induction, the actual surgical procedure , or during the postoperative recovery period. These risks and complications could lead to cardiac, respiratory, metabolic or neurological alterations, or lead to a state of coma or even death; although the incidence of these events is extremely low (around 0.7/10,000)).
A series of side effects or discomfort such as sore throat, coughing, hoarse voice, nausea or vomiting, might occur following general anaesthesia; and headache or back pain following spinal anaesthesia; or haematomas following any type of local anaesthesia.
| 2. . INDIVIDUAL RISKS |
| As per the personal circumstances: ............................................................................................................................. |
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3. I have been informed of the possibility of an expected situation developing during the procedure that might require a different or additional procedure to that planned initially. In such instance, I hereby authorise the medical team to carry out any medical procedure or act as deemed necessary.
4. . I have been informed to strictly follow the following preoperative instructions: to fasten (to be on empty stomach) for a minimum of 6 hours, to take my regular medication (unless otherwise instructed by the physician), not to wear any makeup (lipstick or nail polish), to inform the staff of any type of movable/removable prostheses (contact lenses or dentures) and to inform the staff upon my admittance to the hospital of any anomaly or problem I might have had since my last visit with my doctor/surgeon.
Given that the information given to me has been explained in a understandable manner and that all my questions have been answered to my entire satisfaction, either when reading or when listening to the information concerning the specific anaesthetic procedure, I hereby AUTHORISE THE DEPARTMENT OF ANAESTHESIOLOGY to carry out the above mentioned anaesthetic procedure.
I understand that the signing and granting of this informed consent form does not waive any of my rights to undertake possible future claims, either legal or medical. I also understand that I am free to withdraw this consent form at any moment prior to the procedure.
Signature of the informing physician
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Signature of the informed patient
informat
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Signature of the patient’s legal representative
legal del pacient
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| In Barcelona, on this ------------- of ------------------------------------ of .......................................................... |
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