麻醉知情同意书
Informed Consent Form of Anesthesia
姓名 性别 年龄 房间号 档案号
Name: Gender: Age: Room No.: Record No.:
术前诊断
Pre-surgery Diagnosis:
手术名称： 麻醉方式：
Name of surgery: Anesthesia Mode:
本人自愿接受贵院 手术，经与医生商定，采用 麻
醉。我已完全明白麻醉是保证手术顺利的重要环节，为了顺利的完成手术，麻醉师已清楚地告知本
人所有环节注意事项及麻醉可能出现的一些风险：如术中恶心，呕吐，头晕，窒息，呼吸抑制，
甚至心跳骤停等，本人对此表示理解，并同意授权麻醉医师在必要时采取一切措施，保证本人的
生命安全平稳的完成手术过程。
I voluntarily accept your surgery.Through consultation with the doctors,
anesthesia is adopted. I have complete understood that anesthesia is an important
link to guarantee a smooth surgery. To smoothly complete the surgery,the anesthesiologist has clearly informed me
of the precautions of all links and some potential risks of the anesthesia: such as nausea, vomit, dizzy, asphyxia,
respiratory depression and even cardiac arrest during the surgery. I have understood and agreed all measures that
the anesthesiologist may adopt when necessary, to ensure my life safely and stably complete the surgery.
本人已遵照医师指示，在 小时前（具体时间为 年 月 日 时），未
曾进食，进饮。若未如实告知医师，一切后果自负。
I have abided by the instructions of surgeon, and have not yet taken food or drunk hours before {the speci
fic time is: (year) (month) (day) (hour)(a.m. or p.m.)}. In case I fail to tell the surg
eon the truth, all consequesces in curred there of will be borne
by myself.
祝手术顺利！
Wish you a successful surgery!
贵宾签名：
VIP Signature:
麻醉医师签名：
Signature by the Anesthesiologist:
年 月 日
(Year) (month) (day)
