I have been informed and understand that occasionally there are complications from the anesthetic procedure. Common complications include sore throat and/or hoarseness, cough, nausea, and vomiting. Less common complications include but are not limited to pain, swelling, numbness, infection, bruising, bleeding, muscle aches, headache, phlebitis, injury to lips or teeth from airway instrumentation, nasal injury due to passage of a breathing tube, skin discoloration, allergic reaction. Extremely rare complications include lung infection or aspiration, nerve injury, stroke, heart attack, brain damage and death. I have been made aware that the risks associated with local anesthesia, sedation, and general anesthesia varies. Although local anesthesia is usually considered to have the least risk relative to sedation and general anesthesia, local anesthesia alone sometimes is not appropriate for every patient and every procedure.

I understand that anesthetics, medications and drugs may be harmful to an unborn child. I certify that to my knowledge the patient is not pregnant or trying to become pregnant.

I understand the use of tobacco and alcohol can be detrimental to the success of my treatment.

I consent to the anesthesia and related procedures deemed appropriate by my anesthesiologist. I acknowledge that I have read this form or had it read to me, and that I have been given sufficient time to understand and ask questions. I understand the risks, benefits, alternatives, and the expected result of the proposed treatment.