Epidural Registration Forms

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Obstetrical Pre-Op Anesthesia Evaluation

Authorization and Consent for Performance of Obstetrical Anesthesia

1. I do hereby consent to and authorize Associated Anesthesiologists, Inc. through its’ Anesthesiologists and CRNA’s to administer Obstetrical Anesthesia to me.

I consent

2. I have received and read the pamphlet entitled: Your Anesthetic Labor and Delivery, which explains possible alternative methods of anesthesia and the material risks involved despite precautions, and have been given an opportunity to ask any questions I had concerning Anesthesia, and I understand the possible alternate methods of anesthesia and the material risk involved.

I acknowledge this statement

3. I acknowledge that no guarantee or assurance had been given by anyone as to the results that may be obtained. I also recognize that if I am obese, it may be technically difficult or impossible to receive adequate Epidural or Spinal Anesthesia.

I acknowledge this statement

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Insurance Information Deposit is $286.00 for PPO plans. Self-Pay Deposit is $1137.50. No Deposit for Sooner Care/Medicaid, Blue Lincs, or Blue Federal.

Patient Information

If I am transferred to another hospital I authorize the release of funds paid to Associated Anesthesiologists, Inc. to the Anesthesiologists group administering the Epidural.

I authorize this statement.

Anesthetic History: Please answer yes or no to the following questions

Cardiovascular: Please answer yes or no to the following questions

Lungs: Please answer yes or no to the following questions

Nervous System: Please answer yes or no to the following questions

Kidney & Bladder: Please answer yes or no to the following questions

Gastrointestinal: Please answer yes or no the following questions

Liver: Please answer yes or no to the following question

Diabetes: Please answer yes or no to the following questions

Eyes: Please answer yes or no to the following questions

Dental: Please answer yes or no to the following questions

Blood: Please answer yes or no to the following questions

Airway: Please answer yes or no to the following questions

Back: Please answer yes or no to the following questions

Medications : Please answer the following questions

Your information will be encrypted.

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