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Surgical Chart Audit Tool: Request for Administration of Anesthesia Services Mobile App

Use the Surgical Chart Audit Tool: Request for Administration of Anesthesia Services mobile app to have surgical patients read and complete a Request for Administration of Anesthesia Services Form. The app captures patient and witness signatures. Audits in the GoCanvas Application Store can easily be modified to match your audit in only minutes. You can Customize an app by editing one from the Application Store.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Surgical Chart Audit Tool: Request for Administration of Anesthesia Services Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Patient Name:

  • Ico camera

    Patient Label:

  • Ico date

    Date:

  • Ico statictext

    I the patient or patient relative or guardian, acting on his/her behalf, and asking to receive an...

  • Ico statictext

    It has been explained to me that all forms of anesthesia involve some risks.

  • Ico statictext

    I understand that medication(s) that I am taking may cause complications with anesthesia and that...

  • Ico statictext

    I understand that if I am pregnant, any medication I may receive may have an adverse effect on th...

  • Ico statictext

    Should the need arise preceding my procedure/operation/treatment or in the post-operative period,...

  • Ico statictext

    I consent to appropriate tests and treatments that may evaluate better my risk and prepare me for...

  • Ico statictext

    I understand that while I am receiving anesthesia, conditions may develop which require modifying...

  • Ico statictext

    I understand that my anesthesia care will be given to me by or under the supervision of an attend...

  • Ico statictext

    By signing this request form, I indicate that I fully understand the contents of this document, a...

  • Ico statictext

    I acknowledge that I know the practices of anesthesiology, medicine, and surgery are not exact sc...

  • Ico statictext

    I consent to the following anesthetic Plan: General/TIVA/MAC with sedation/MAC without sedation/R...

  • Ico signature

    Signature of patient/parent/guardian

  • Ico date

    Date

  • Ico time

    Time

  • Ico signature

    Witness

  • Ico textbox

    I Dr.

  • Ico statictext

    attest that this patient or the representative named above has been informed about the common for...

  • Ico signature

    Signature of anesthesiologist

  • Ico date

    Date

  • Ico time

    Time

  • ...and More!

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