Epidural Registration Forms

Obstetrical Pre-Op Anesthesia Evaluation

Patient Name

Patient DOB

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

4. I prefer to have the Continuous Lumbar Epidural if such procedure is deemed practical by the Anesthesiologist in charge of my Anesthesia. (THIS IS THE EPIDURAL YOU ARE SIGNING UP FOR) Initial if appropriate:

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.

Date

Sign full name here

Facility of Scheduled Delivery

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.

Insurance Type: (If no insurance, please put “Self-Pay” below.)

Name of Insurance Carrier

Name of Policy Holder

Member ID Number

Do you have any additional insurance or coverage?

Name of additional insurance carrier (if applicable)

Name of Policy Holder

Member ID Number

Patient Information

Hospital you are delivering at:

Patients Name in Full

Birthday

Age

Address

City

State

Zip

Email address

Obstetricians Name (OB GYN):

Due Date

Patients Employment

Social Security #

Business Phone

Home Phone

Spouse Employment

Spouse Name

Spouse Social Security #

Business Phone

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.

Height

Current Weight as of today:

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

Have you had a previous delivery?

Yes No

Have you had an epidural?

Yes No

Have you had a spinal block?

Yes No

Have you had a C-Section?

Yes No

Have you had general anesthesia?

Yes No

Any previous anesthetic problems?

Yes No

Family history of complications?

Yes No

Cardiovascular: Please answer yes or no to the following questions

Heart murmur / Heart Valve Disease

Yes No

Rheumatic fever

Yes No

Irregular heart beat

Yes No

Chest pain

Yes No

Heart attack

Yes No

High blood pressure

Yes No

Phlebitis

Yes No

Surgery on heart or arteries

Yes No

Lungs: Please answer yes or no to the following questions

Cough or cold at present time

Yes No

Frequent bronchitis or pneumonia

Yes No

Asthma/Wheezing

Yes No

Emphysema

Yes No

Do you smoke or did you smoke?

Yes No

If yes, packs per day / how many years?

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

History of brain disease

Yes No

History of spinal cord disease

Yes No

History of stroke

Yes No

History of epilepsy or seizures

Yes No

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

History of infections

Yes No

History of stones

Yes No

History of kidney failure

Yes No

Gastrointestinal: Please answer yes or no the following questions

Do you have a hiatal hernia?

Yes No

Have you had a stomach ulcer?

Yes No

Liver: Please answer yes or no to the following question

History of hepatitis or jaundice?

Yes No

Diabetes: Please answer yes or no to the following questions

Do you take insulin?

Yes No

Do you take a diabetes pill?

Yes No

Are you on a diabetic diet?

Yes No

Eyes: Please answer yes or no to the following questions

Do you have contact lenses?

Yes No

Do you have glaucoma?

Yes No

Do you have intraocular lenses?

Yes No

Dental: Please answer yes or no to the following questions

Dentures, bridges, crowns, caps

Yes No

Loose, chipped, missing or broken teeth

Yes No

Blood: Please answer yes or no to the following questions

Sickle cell trait / disease

Yes No

Previous blood transfusions

Yes No

Abnormal bleeding

Yes No

Airway: Please answer yes or no to the following questions

Problem opening mouth wide

Yes No

Problem moving neck

Yes No

Trouble breathing through nose

Yes No

Tongue stud / ring

Yes No

Back: Please answer yes or no to the following questions

Previous back surgery

Yes No

Previous back injury

Yes No

Back pain during pregnancy

Yes No

Do you have scoliosis?

Yes No

Medications : Please answer the following questions

What medications are you taking if any?

Do you have any drug allergies?

Do you have a history of alcohol / drug abuse?

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