Informed Consent-Wps Office

INFORMED CONSENT FOR ANAESTH
Patients Name:-
Age/Sex:- Bed No.-
-
1.I hereby authorize Dr_
anaesthesia on myself/my_
I have been explained and l permit performance of the suitable anaesthesia technique on me fo
conduction of surgical procedure.
2.One of the following anaesthesia technique will be used on me:-
Microbiology 1.General Anaesthesia-Done through inhaled anaesthetic agent and/or Intravenous use o
anaesthetic medication.This will cause unconsciousness,muscle relaxation and analges
The un-consciousness reverses after withdrawal of anaesthetic agent
Kardex 2.Deep Sedation-This leads to sedation and analgesia and is achieved through intraveno
and inhaled agents
Lab Results 3.Regional anaesthesia-This can be done through spinal,epidural or caudal nerve block.
The process causes temporary loss of sensation and pain in certain areas of body
l understand that in case deep sedation or regional anaesthesia is not satisfactory,general

anaesthesia may be used.
l understand that during my operation if condition requires change in course of action,my
anaesthesia provider will act on my behalf for my benefit and safety.
3.I understand that Anaesthesia administration is associated with various risks up-to death of
patient.While my anaesthesiologist will take all professional care,no guarantee can be made for
outcome of anaesthesia.
Common side effects associated with Anaesthesia include(but not limited to),nausea and vomiti
adverse drug reaction,bronchospasm,laryngospasm,arrhythmias,dreams or recall of intra-
operative events,corneal abrasions,and damage to mouth,teeth,or vocal cord,backache.Po
Dural puncture spinal headache,massive block,neurological injury (Cauda equine syndrome,
numbness,pain or paralysis,epidural or spinal haematoma,meningitis,damage to arteries,vein
and in rare cases permanent brain damage,heart attack,stroke,or death.
4.I also acknowledge that I have truthfully
disclosed,to the best of my knowledge,all
medical
history and condition,asked to me.
Signature and name of the person giving consent
Relationship with the patient
Signature and name of the witness
Signature and name of the doctor taking consent

OR ANAESTHESIA
UID No
for administration of
(name of patient).
sthesia technique on me for
nt and/or Intravenous use of

uscle relaxation and analgesia.
etic agent
achieved through intravenous
dural or caudal nerve block.

certain areas of body
ot satisfactory,general
course of action,my
rious risks up-to death of

guarantee can be made for
mited to),nausea and vomiting,

eams or recall of intra-
r vocal cord,backache.Post-
Cauda equine syndrome,
itis,damage to arteries,veins
ath.
Republic of the Philippin
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDI
Baguio City
DEPARTMENT OF PATHOLOGY-MOLECULAR
MOLECULAR BIOLOGY LABORATORY RE
Name: Ananias, Lilian Jules
Age/Sex: 20/F
LOCATION
Region :Region 1 Ward: GYNE
Referral:
Date and Time of Specimen Collection

Type of Specimen
05/18/2024 8:15 AM OPS/NPS
Date and Time Performed

05/018/20
Laboratory Test Result

Laboratory Test Performed:
Test Result:
RESULT AND UNIT OR MEASURES:
BIOLOGICAL REFERENCES INTERVALS:
Final Result
Invalid due to specimen quality
This laboratory result should be interpreted together with the available clinical and epidemiological informat
Comments/Remarks:
ROMMEL C.VERGANIO,RMT
IVAN RAY U:MOLINA,RMT
Medical Technologist Section Manager,Molecular Biology
Laboratory
PhilHealth Accredited
Your Partner in Health
Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Form
No:MS-PAT-MBL-
ATHOLOGY-MOLECULAR LABORATORY 002
Revision No:0
OLOGY LABORATORY RESULT FORM Effectivity
Date:March
26,2020
Specimen No.:
Laboratory No :0001640415
Date Admitted :N/A
Date of Birth: 05/05/2004
Address: Cervantes, Ilocos Sur
Date and Time of Specimen

Receipt
OPS/NPS 05/18/24
Attending Physician/Attending Investigator

DR.MA.JONELYN MENDOZA
st Result
NONE
NONE
Interpretation
Negative for test internal control (most likely due to poor

specimen quality)
cal and epidemiological information.
KAREN C TUBA-
RGANIO,RMT
ANG,MD,FPSP
Head,Molecular Biology
olecular Biology Laboratory
boratory
KARDEX
PATIENT NAME: Ananias, Lilian Jules D.

PHYSICIAN: Dr.Jomaya
Date Admitted: 05/17/2024
Diagnosis
DIAGNOSTICS
MEDICATIONS
IV FLUIDS
SPECIAL ENDORSEMENTS
TREATMENT
PROCEDURES
DIET
NURSING NEEDS
KARDEX
AGE:59 HOSPITAL NO.: 000000002004

SEX:male WARD/ROOM: Gyne Ward
Chief pain and itchiness

Allergies
DATE ORDERED NURSING ACTION


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INFORMED CONSENT FOR ANAESTH

1.I hereby authorize Dr_

2.One of the following anaesthesia technique will be used on me:-

l understand that in case deep sedation or regional anaesthesia is not satisfactory,general

Relationship with the patient

Signature and name of the witness

Signature and name of the doctor taking consent

nt and/or Intravenous use of

achieved through intravenous

dural or caudal nerve block.

rious risks up-to death of

mited to),nausea and vomiting,

Name: Ananias, Lilian Jules

Region :Region 1 Ward: GYNE

Date and Time of Specimen Collection

05/18/2024 8:15 AM OPS/NPS

Date and Time Performed

Laboratory Test Result

Invalid due to specimen quality

Date Admitted :N/A

Date of Birth: 05/05/2004

Address: Cervantes, Ilocos Sur

Date and Time of Specimen

Attending Physician/Attending Investigator

Negative for test internal control (most likely due to poor

cal and epidemiological information.

PATIENT NAME: Ananias, Lilian Jules D.

Date Admitted: 05/17/2024

AGE:59 HOSPITAL NO.: 000000002004

Chief pain and itchiness

DATE ORDERED NURSING ACTION

DATE ORDERED NURSING ACTION

DATE ORDERED NURSING ACTION

DATE ORDERED NURSING ACTION

DATE ORDERED NURSING ACTION

DATE ORDERED NURSING ACTION

DATE ORDERED NURSING ACTION

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