• Ophthalmic Mutual Insurance Company (OMIC)

    Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent. Document in the patient’s chart that he/she received information regarding general anesthesia.

    I , __________________, have been informed that the proposed surgery will be performed under general anesthesia. Although my doctor will not be administering the general anesthesia himself, he has told me that it will be administered by a qualified and licensed individual. I have been made aware of the need for this type of anesthesia and have been informed by my doctor of the following facts about general anesthesia:


    • General anesthesia produces an unconscious state; the whole body is affected. This type of anesthesia is produced by injecting drugs into the patient’s blood stream and by having the patient inhale other drugs (anesthetic gas).
    • Frequently, the person who administers the anesthetic places a tube through the mouth or nose of the patient into the trachea (windpipe) to aid in managing the patient’s breathing (oxygen needs) and amount of the anesthetic gas. Occasionally, on recovering from general anesthesia, the patient will note soreness and pain in the mouth and throat areas from abrasions. If it is necessary to place a tube through the nose, nosebleeds may occur.
    • Although very rare, strokes, brain damage, heart attacks and pneumonia are known complications of general anesthesia. All types of anesthesia involve some risk. Complications from all forms of anesthesia are rare, but may occur. There is a very remote possibility of death as a complication of general anesthesia.
    • Other known complications of general anesthesia include (but are not limited to) broken teeth, allergic reactions, infection, liver failure, kidney damage, bleeding, blood clots, loss of limb function and paralysis.
    • General anesthesia complications occur rarely. They can happen, unpredictably, regardless of the experience, care and skill of the anesthesia provider.

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