Anesthesia Informed Consent Form in EnglishInformed Consent for AnesthesiaName of patient Gender Age Registry NoDiagnosis Prep-opName of the surgery proceduresType of Anesth

esia.□ Rare but serious complications such as stroke, heart attack, and death may occur.□ Other possible complications may occur during anesthesia or surgery, which cannot be predicted in advance.I have been informed of the risks, benefits, and alternatives to anesthesia and have had the opportunity to ask questions. I understand that I may refuse anesthesia or withdraw my consent at any time. I authorize the administration of anesthesia and understand that the anesthetist, anesthesia provider, and/or surgeon will take all reasonable precautions. I understand that there is no guarantee or warranty as to the results or cure.I have read and understand the above information and have had my questions answered. I voluntarily consent to the administration of anesthesia and any related procedures. I understand that I may request a copy of this consent form.Signature of patient: Date:Signature of witness: Date:Signature of anesthesia provider: Date