GHAISAS ENT HOSPITAL
Govind 1248-B Deccan Gymkhana, Pune 411004
PMC/LCBP/0506/01279
Name of patient:
…………………………………………………………………………………………………….. Age:
…… Sex: …… Reg no: …….. Address: ………
Diagnosis: Tonsillitis
Operation title: Tonsillectomy (Dissection and Snare Method)
I, ……………………………………………………………………..……the undersigned give
consent for my own operation.
The following procedure will be performed:
Tonsillectomy will be done under General anesthesia.
The expected outcome and likelihood of success is: Good/ Fair/Poor
Risks of the procedure: There are risks and complications with this procedure.
They include but are not limited to the following.
General risks:
Bleeding could occur and may require a return to the operating room. Is the
patient on blood thinning drugs such as Warfarin, Asprin, Clopidogrel or
Dipyridamole.
Infection can occur, requiring antibiotics and further treatment.
Small areas of the lung can collapse, increasing the risk of chest infection. This
may need antibiotics and physiotherapy.
Increased risk in obese people of wound infection, chest infection, heart and
lung complications, and thrombosis (DVT).
Cardiac arrest and death as a result of this procedure
Specific risks (if any; for this particular patient)
Bleeding. This may occur either at the time of surgery or in the first 2 weeks
after surgery. Delayed bleeding may require re-admission to hospital and may
require another operation to stop the bleeding.
A blood transfusion may be necessary depending on the amount of blood lost.
Burns from the equipment used to seal off bleeding areas during the operation.
Infection. Persistent bad breath, worsening throat discomfort or delayed
bleeding, usually treated with antibiotics.
Pain. Moderate throat pain is common during the first 2 weeks after surgery,
requiring regular analgesia. Rarely, pain in the area back of the tongue or back
of the throat.
Injury to the teeth, lips, gums or tongue. There can also be a temporary
change in sensation to tongue.
Abnormal scarring may rarely occur causing narrowing or stenosis of the
throat.
Recurrence – regrowth of Tonsil tissue left behind.
Alternatives to this procedure: There is no other alternative treatment for this
disease other than using antibiotics which has temporary improvement and side
effects.
I acknowledge that the Dr has explained;
• My medical condition and the proposed procedure, including additional
treatment if the doctor finds something unexpected. I understand the risks,
including the risks that are specific to me.
• The anesthetic required for this procedure. I understand the risks, including
the risks that are specific to me.
• My prognosis and risks of not having the procedure.
• The procedure may include a blood transfusion.
• I have been explained that excessive bleeding, infection, cardiac arrest,
pulmonary embolism and complications like this can arise suddenly and
unexpectedly while undergoing operative procedure or anesthesia.
• During surgery suspected body tissues could be removed for
histopathological examination.
• I give consent for any change in anesthesia or operative procedure at the
time of surgery.
I have been made aware that after the above operation and anesthesia
some complication may arise and I believe that to avoid such complications,
if any appropriate care is needed it shall be taken by surgeon and
anesthetist or any other Doctor suggested by them
That there is no ICU in this hospital but this hospital has a tie up with
……………………………………………….. hospital which has ICU back up and
patient will be shifted there in case of any complication so that appropriate
care can be taken of.
• I was able to ask questions and raise concerns with the doctor about my
condition, the proposed procedure and its risks and my treatment options.
My questions and concerns have been discussed and answered to my
satisfaction.
• I understand I have the right to change my mind at any time, including after
I have signed this form but, preferably following a discussion with my doctor
• I understand that images or video footage may be recorded as a part of and
during my procedure.
• I accept that medicine is not an exact science and understand that no
guarantees can be given to the results and understand these limitations.
• I, have read the above writing/ the above writing has been read out to me
and is explained to me in the ……………language by……………….(interpreter)
which I understand.
• I have understood the aforesaid and I am giving my consent willingly with
sound mental state without any Coercion, Undue influence, Fraud,
Misrepresentation or Mistake of facts.
• I request Dr. ……………………….………..to perform upon me the above
mentioned procedure.
• The competent courts in Pune will have jurisdiction in relation to any
claim/dispute arising from or relating to the procedure(s) mentioned herein.
Declaration by doctor: I declare that I have explained the nature and
consequences of the procedure to be performed, and discussed the risks that
particularly concern the patient.
I have given the patient an opportunity to ask questions and I have answered
these.
• Doctor Patient/Guardian
Sign…… Sign/lt thumb imp....
Name………. Name………….
Address………. Address……….
Date….. Date……Age…..
Time……… Time…………..
• Witness Witness
Sign…….. Sign………
Name……….. Name……….
Relation with patient….. Relation with patient….…
Address…….. Address………….
Date…Age………. Date…….Age………
Time…….. Time………….
GHAISAS ENT HOSPITAL
Govind 1248-B Deccan Gymkhana, Pune 411004
PMC/LCBP/0506/01279
Name of patient:
……………………………………………………………………………………………….…. Age:
…… Sex: …… Reg no: …….. Address: ………
Diagnosis: Tonsillitis
Operation title: Tonsillectomy ( Coblation / Laser / Radiofrequency) ….(Tick
appropriate)
I, ……………………………………………………….…the undersigned give consent for my
own operation.
or
We/I hereby certify that We/I are/am the parent(s) or guardian(s) of the above
named child and do hereby give our/my consent for the above mentioned
operation on my child.
The following procedure will be performed:
Tonsillectomy will be done under General anesthesia
The expected outcome and likelihood of success is: Good/ Fair/ Poor……..
Risks of the procedure: There are risks and complications with this procedure.
They include but are not limited to the following.
General risks:
Bleeding could occur and may require a return to the operating room. Is the
Patient on blood thinning drugs such as Warfarin, Asprin, Clopidogrel or
Dipyridamole.
Infection can occur, requiring antibiotics and further treatment.
Small areas of the lung can collapse, increasing the risk of chest infection. This
may need antibiotics and physiotherapy.
Increased risk in obese people of wound infection, chest infection, heart and
lung complications, and thrombosis (DVT).
Recurrence – regrowth of Tonsil tissue left behind.
Cardiac arrest and death as a result of this procedure
Specific risks (if any; for this particular patient)…..
Bleeding. This may either at the time of surgery or in the first 2 weeks after
surgery. Delayed bleeding may require re-admission to hospital and may
require another operation to stop the bleeding.
A blood transfusion may be necessary depending on the amount of blood lost.
Burns from the equipment used to seal off bleeding areas during the operation.
Infection. Persistent bad breath, worsening throat discomfort or delayed
bleeding, usually treated with antibiotics.
Pain. Moderate throat pain is common during the first 2 weeks after surgery,
requiring regular analgesia. Rarely, pain in the area back of the tongue or back
of the throat.
Injury to the teeth, lips, gums or tongue. There can also be a temporary
change in sensation to tongue.
Abnormal scarring may rarely occur causing narrowing or stenosis of the
throat.
Alternatives to this procedure: There is no other alternative treatment for this
disease other than using antibiotics which has temporary improvement and side
effects.
I acknowledge that the Dr has explained;
• My medical condition and the proposed procedure, including additional
treatment if the doctor finds something unexpected. I understand the risks,
including the risks that are specific to me.
• The anesthetic required for this procedure. I understand the risks, including
the risks that are specific to me.
• My prognosis and risks of not having the procedure.
• The procedure may include a blood transfusion.
• I have been explained that excessive bleeding, infection, cardiac arrest,
pulmonary embolism and complications like this can arise suddenly and
unexpectedly while undergoing operative procedure or anesthesia.
• During surgery suspected body tissues could be removed for
histopathological examination.
• I give consent for any change in anesthesia or operative procedure at the
time of surgery.
• I have been made aware that after the above operation and anesthesia
some complication may arise and I believe that to avoid such complications,
if any appropriate care is needed it shall be taken by surgeon and
anesthetist or any other Doctor suggested by them.
• That there is no ICU in this hospital but this hospital has a tie up with
……………………………………………….. hospital which has ICU back up and
patient will be shifted there in case of any complication so that appropriate
care can be taken of.
• I was able to ask questions and raise concerns with the doctor about my
condition, the proposed procedure and its risks and my treatment options.
My questions and concerns have been discussed and answered to my
satisfaction.
• I understand I have the right to change my mind at any time, including after
I have signed this form but, preferably following a discussion with my doctor
• I understand that images or video footage may be recorded as a part of and
during my procedure.
• I accept that medicine is not an exact science and understand that no
guarantees can be given to the results and understand these limitations.
• I, have read the above writing/ the above writing has been read out to me
and is explained to me in the ………language by…….(interpreter) which I
understand.
• I have understood the aforesaid and I am giving my consent willingly with
sound mental state without any Coercion, Undue influence, Fraud,
Misrepresentation or Mistake of facts.
• I request Dr. ……………………………………..to perform upon me the above
mentioned procedure.
• The competent courts in Pune will have jurisdiction in relation to any
claim/dispute arising from or relating to the procedure(s) mentioned herein.
Declaration by doctor: I declare that I have explained the nature and
consequences of the procedure to be performed, and discussed the risks that
particularly concern the patient.
I have given the patient an opportunity to ask questions and I have answered
these.
• Doctor Patient/Guardian
Sign…… Sign/lt thumb imp....
Name………. Name………….
Address………. Address……….
Date….. Date……Age…..
Time……… Time…………..
• Witness Witness
Sign…….. Sign………
Name……….. Name……….
Relation with patient….. Relation with patient….…
Address…….. Address………….
Date…Age………. Date…….Age………
Time…….. Time………….
GHAISAS ENT HOSPITAL
Govind 1248-B Deccan Gymkhana, Pune 411004
PMC/LCBP/0506/01279
Patient’s Name:
Age: years Sex: M/F Address:
Phone No:
OPD Reg No: Surgery proposed:
Surgeon: Dr Anaesthesiologist: Dr
General anaesthesia involves rendering a patient unconscious before an
operation. This is to ensure that the patient is not aware of events and does not
feel pain during the operation. Drugs are given through vein and/or inhaled
from gases delivered by anaesthesia machine. Regional anaesthesia involves
using a local anaesthetic to numb a specific part of the body for surgery
or pain relief. Prolonged pain relief without numbness cab be achieved by
infusing appropriate concentrations of local anaesthetics with adjuvants in the
regional blocks during the anaesthetic for surgery or after injury.
The following questionnaire will help to assess you during the Pre Anaesthetic
Check performed by the anaesthesiologist.
1. Do you have any chronic medical condition for which you need to visit a
doctor regularly?
If yes give details
2. Do you take any medicines other than those stated in answer to Q 1?
If yes give details
3. Do you have any of the following:
Heart Disease Blood pressure DiabetesKidney Disease Liver Disease
Asthma/Bronchitis
Thyroid If yes give details
4. Do you feel breathless on walking? How much can you walk without
stopping? How many floors can you climb at normal pace without
stopping?
5. Have you undergone any surgery in the past?
If yes give details
Did you need anaesthesia for it? If yes give details
6. Do you have any known allergy?
If yes give details
7. Have you been admitted to hospital or received any prolonged treatment
for any medical condition?
If yes give details
8. Do you smoke, consume alcohol, tobacco, pan, gutka, supari etc.? If yes
give details
9. Have you received blood transfusion in the past? Y/N
10. Have you tested positive for HIV/HBsAg/ other viral infections? Y/N
11. Do you have loose teeth, removable denture? Y/N
12. Do you use hearing aid? Y/N
Do you have any concerns? If yes
give details
Patient’s Sign
Pre anaesthetic
check-up:
(to be performed by qualified
Anaesthesiologist)
History:
General Examination: Airway
Assesment:
Spine:
Pulse:
Blood Pressure:
Systemic Investigations: Hb: Creat:
Examination:
RS:
CV
S:
ECG:
P/A:
CNS
:
ASA Grade: I/II/III/IV/V
Emergency
Anaesthesia alerts:
Sign
. ( Dr.
)
Important Do's &
Don’ts
1) Please be, 'Nil by mouth' 6 hours
before surgery
2) Know your Anaesthetist & Anaesthesia
before the surgery.
3) Remove all lipstick, nail polish, ornaments
before surgery.
4) Keep mobiles, keys, valuables with
responsible relatives.
5) Do not consume alcohol, tobacco & do not smoke before
or after the surgery.
6) Do not take anything by mouth without doctor’s
permission after surgery.
7) Do not go home alone
after surgery.
8) Do not drive vehicle, do cooking or use equipment
on day of surgery.
9) Please contact the doctor for
any problem.
COMPLICATIONS AND PROVISION
OF CARE
Anaesthesia Care: Your anaesthetist is a qualified post graduate & is well versed
with dealing with all types of situations that can occur during any life threatening
situation one may see in the ICU.
Complications: Anaesthesia has become safer and safer; however, there remains
the risk of complications with any anaesthetic rendered.
There remains a risk of death or organ injury; however, this risk is extremely low
for the vast majority of patients. Below we list some of the more common side
effects or complications of specific anaesthetic techniques. It is always possible
that a general anaesthetic may be employed if another technique is not
satisfactory.
General
Anaesthesia
1. Nausea: your anaesthesia team tries to recognize those at highest risk for
nausea in order to minimize this risk. Alert us if you have a history of
postoperative nausea.
2. Dental trauma: teeth, especially when in poor repair or when there is
dental work or dental prostheses,
can be injured during or after anaesthesia. A sore throat is common after
general anaesthesia because of placement of a breathing tube.
3. Nerve injury: we make every effort to prevent injury to nerves while in the
operating room; however, there remains a small risk of nerve injury with
surgery and anaesthesia, though most of these injuries improve within
days. Incidence of nerve injury may be increased with certain surgical
positions, duration of procedure, and body habitus.
Consent for
Anaesthesia:
I, , for as
Parent,/Guardian/ Representative acting on
his/her or my behalf, am seeking to receive anaesthesia during his/her or my pending
procedure/operation/treatment. I
want to have anaesthesia in order to lessen the pain I would
otherwise experience.
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.
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
anaesthesiologist and his / her team with associates or assistants of his / her
choice to induce anaesthesia mentioned hereinabove during the course of the
proposed intervention
/ procedure / surgery and also to administer the requisite
drugs and medications.
I understand that regardless of the type of anaesthesia used there may be some unforeseen risks
and consequences which may occur. The following are some but not all of the common foreseeable
risks and consequences which I have been told can occur: sore throat and hoarseness, nausea and
vomiting, muscle soreness. Further, I understand instrumentation in the mouth to maintain an open
airway during anaesthesia might unavoidably result in dental damage including fracture or loss of
teeth, bridgework, dentures, crowns and fillings, laceration of the gums or lips.
I understand that medications that I am taking may cause complications with anaesthesia or
surgery. I understand that it is in my best interest to inform my doctors about the nature of any
medications Allopathic / Homoeopathic / Ayurvedic / Unani I am taking including but not limited to
aspirin, cold remedies, narcotics, marijuana, and cocaine.
I have been explained and have understood that inducing anaesthesia 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 anaesthesia. I understand the more serious risks and
consequences of anaesthesia include but are not limited to changes in blood pressure, allergic/drug
reaction, awareness of the surgery, injury to my baby if pregnant, excessive bleeding, cardiac
arrest, brain damage, embolism, paralysis or death.
I have been explained and have understood that despite all precautions
complications may occur that may even result in death or serious disability.
has told me that in his/her medical judgment the type(s) of
anaesthesia I could receive
I acknowledge
that Dr.
is/are General Anaesthesia /Spinal / Epidural Anaesthesia /MAC (Monitored Anaesthesia Care)
/ Sedation / Regional anaesthetic block. I have listened to the doctor's explanation of the type(s)
of anaesthesia I may receive, its benefits and common foreseeable risks and consequences as well
as those of its alternatives and now accept his/her recommendation . I have been explained
and understood that though the plan of anaesthesia has been explained to me,
there is a possibility that a different plan may be adopted due to various unseen
circumstances that may arise during the anaesthetic.
I understand that during my procedure/operation/treatment invasive monitoring may be necessary.
I understand the risks and benefits associated with this type of monitoring which have been fully
explained to me.
I understand that while I am receiving anaesthesia, conditions may develop which require
modifying or extending this
consent. I therefore authorize modifications or extension of this consent that professional
judgment indicates to be necessary under the circumstances. I understand that I must not eat or
I have
drink anything 6 hours prior to surgery unless directly permitted by the anaesthesia-staff.
been explained and have understood the importance of preoperative fasting and
the risks of consuming solids/liquids prior to the induction of anaesthesia
I consent to appropriate tests and treatments which may better evaluate my risk
and prepare me for surgery as part of my medical care associated with this
procedure/operation/treatment.
I, the undersigned patient, give my consent to discuss my personal health
information with any person that accompanies me or is present with me that I
have identified in advance of any procedure as active in my mental, physical,
emotional, or spiritual care, including, but not limited to family, close personal
friends, and patient advocates. I also authorize Mr/Ms.
accompanying me to give consent on my behalf with regards to any anaesthetic, surgical or other
medical intervention required when I am undergoing an anaesthetic.
I am aware of the facilities which are available and not available in the hospital. I
may have to be shifted to another hospital for treatment of complications and I am
bound to pay the bill of that hospital.
PATIENT
AFFIRMATION
By signing this document, I am indicating that I understand the contents of this
document and its attachments, agree to its provisions and consent
to the administration of anaesthesia during my
procedure/operation/treatment. I know that if I have concerns or would like more
detailed information, I can ask more questions and get more information from my
attending anaesthetist. I am also acknowledging that I know that the practice of
anaesthesiology, medicine and surgery is not an exact science and that no one
has given me any promises or guarantees about the administration of anaesthesia
or its results. I fully understand what I am now signing of my own free will and the
above12 points in the consent form have been explained to me thoroughly in my
own language.
I have signed this consent voluntarily out of my free will and without any
kind of pressure or coercion.
Patient’s Signature
Witness Signature
Date & Time
Witness Name:
