Procedure Name * Required: The specific procedure being consented to.

Patient ID * For linking consent to the correct record.

Risks Explained * Yes No I confirm the risks and benefits were explained to me.

Opportunity to Ask * Yes No Did you have the opportunity to ask questions?

Anesthesia Type * Local General None Indicate the type of anesthesia discussed.

Witness Signature Required * Check this box if a witness is required for consent.

Date of Consent * Required: The date the document was signed.