Dr Jonathan Kay - Specialist Anaesthetist

Dear Patient

• Your answers in this form WILL determine the type and technique of anaesthetic you receive.
• Accuracy and honesty is ESSENTIAL to ensure you receive safe and comfortable anaesthesia
• Please think carefully before answering and make every effort to be as accurate as possible.

I look forward to meeting you and answering any questions you may have on the day of surgery as well as providing a safe anaesthetic for your procedure.

PLEASE READ THE FOLLOWING CONSENT DOCUMENT CAREFULLY BEFORE SIGNING 

 

Acknowledgement of the Risks of Anaesthesia

Modern anaesthesia is safe, however every medical procedure carries inherent risk. Risks of anaesthesia care include (but are not limited to) some of the following

 Common side effects

• Nausea or vomiting
• Headache Sore throat or hoarse voice
• Blurred/double vision and dizziness
• Problems in passing urine.

Less common side effects

• Muscle aches and pains
• Mild allergic reaction - itching or rash
• Damage to teeth and dental work
• Damage to the voice box
• Allergic reactions
• Worsening of asthma or chest infections
• Blood clot formation in the leg or lungs
• Epileptic seizure
• Nerve damage due to the needle when giving an injection, placing a drip or due to pressure on a nerve during the surgery

Rare risks and complications

• Being awake under general anaesthetic
• Very low blood pressure (shock)
• Stroke or heart attack
• Vomit contaminating the lungs (apsiration pneumonia)
• Paralysis or Brain damage.

Specific Risks of Regional Anaesthesia (Nerve Blocks)

• Damage to near-nerve structures (eg blood vessels, lungs)
• Nerve damage due to needle contact, bleeding, infection or other causes.

Nerve damage may cause weakness and/ or numbness of the body part that the nerve goes to. This is usually mild and only lasts a short time. In very rare cases nerve damage may be severe and permanent. 

Special Risks of Spinal and Epidural Anaesthesia

• Headache. (Usually temporary but may be severe and can last many days)
• Backache (Usually temporary due to bruising around the injection site)

It is very important not to eat, drink, chew gum or sweets before your surgery. You will be told when to have your last meal and drink. If you eat or drink after that time, your operation maybe delayed or cancelled

A general anaesthetic will affect your judgment for about 24 hours. For your own safety:

• Do NOT drive any type of car, bike or other vehicle.
• Do NOT operate machinery including cooking implements.
• Do NOT make important decisions or sign a legal document.
• Do NOT drink alcohol, take other mind altering substances, or smoke. They may react with the anaesthetic drugs.
• Have an responsible person with you to assist on the first night after your surgery.

ANAESTHESIA CONSENT AND AGREEMENT

 

Payment of Accounts

1. I understand that an agreement exists between myself and Dr Jonathan Kay Anaesthesiology Inc. for payment of accounts relating to anaesthetic services rendered on the date specified above.
2. I understand that I have a separate agreement with my medical aid and that they may not fully reimburse me or Dr Kay for the full cost of the account as detailed above.
3. I understand and agree that irrespective of authorisations and promises to pay made by my medical aid, I remain personally responsible for the full value of my anaesthetic account.
4. I understand that the cost estimate I have received is time based and may change as a result of unforeseen circumstances and unexpected procedures or complications. I also understand that if additional procedures or services are made necessary by circumstances arising during my anaesthetic that these may also result in additional costs for my account.

Debt Collection, Communication and Dispute

1. I understand that should I not pay within 30 days and my account is handed over for debt collection, interest will be charged on outstanding amounts at 2% per month until fully settled according to the provisions in the National Credit Act 34 of 2005 pertaining to incidental credit agreements.
2. I undertake to pay all legal, debt collection and tracing costs on the attorney and own client scale and charges as stipulated by the Debt Collectors Act 114 of 1998 relating to the recovery of fees outstanding on my account in respect of the anaesthetic services rendered.
3. In the event of any claim, complaint or grievance, I shall, prior to taking any legal action, promptly initiate a free and confidential pre-mediation meeting with an accredited mediator appointed by South African Society of Anaesthesiologists (SASA).
4. I hereby choose the nominated address as my DOMICILIUM CITANDI ET EXECUTANDI for all purposes under this agreement and I hereby agree that any notice sent to the nominated address by registered post will be deemed to have been received by me on the third business day after the posting of it. I further agree that any notice received by me by and means and at any address will be valid for all legal purposes notwithstanding that it was not sent by registered post or to my DOMICILIUM CITANDI ET EXECUTANDI. I agree that should I wish to change my DOMICILIUM CITANDI ET EXECUTANDI I will give one weeks written notice for such change to become effective.

Confidentiality and Protection of Personal Information

1. I agree that personal information collected in terms of this consent is to be utilised for healthcare of the patient, billing and collection of debt as well as processing of queries, complaints or compliments.
2. I authorise the release of any clinical information, including my HIV status to any other member of the medical/ paramedical profession responsible for my safety and treatment.
3. I agree to allow my personal and clinical information to be shared with other persons or institutions (e.g.: medical scheme) if this is necessary to serve a legitimate purpose within the ordinary course and scope of my anaesthesiologist’s duties, provided such disclosure is in my/ the patient’s interests.
4. I understand my personal information is stored in a secure location and is accessible only to third parties with signed confidentiality clauses as part of their employment agreements/ contracts.
5. I consent to sharing patient, guardian and guarantor information with the South African Society of Anaesthesiologists CEO and its Private Practice Business and Regulation Business units in the event of a complaint (which information will be kept confidential within the SASA CEO, Private Practice and Regulation business units).
6. I consent to the sharing of information on my account with other credit grantors and with the credit bureau.
7. I consent to communication with my family/ nominated others with respect to my medical care and medical account.

Patient Declaration

1. I confirm that the purpose of the anaesthetic has been explained in full and that all reasonable complications associated with the administration of anaesthesia have also been explained to me. I understand that an incident-free anaesthetic cannot be guaranteed.
2. I confirm that I have read and taken special note of the risks of anaesthesia and patient instructions above.
3. I have received this agreement, cost estimate and the anaesthesia consent form timeously. I understand the contents and agree to the complaints/ queries procedure.
4. I have been in possession of the Dr Kay’s contact details, and have had an opportunity to contact him to discuss particular concerns regarding the cost estimate, this agreement and my anaesthesia outlined therein before the date of surgery.
5. I consent to communicating with Dr Kay electronically; I consent to receiving messages from Dr Kay electronically and agree that any agreement, notice, disclosure or other message transmitted electronically satisfies any legal requirement.
6. POPI Section 18 Practice Privacy Notification is available on request. I have the right to review the Privacy Notification prior to signing this agreement.
7. I have no further queries or disputes relating to this agreement, the cost estimate or the anaesthesia consent.