The proposed anesthetic(s), along with the risks, benefits and possible discomfort associated with them, have been explained by a representative of Reproductive Health Services. I consent to the administration of such anesthetic.

I certify that I have not had anything to eat or drink since ______________(time).

I certify that I have not used any street drugs in the past 72 hours.

I understand that I cannot drive after anesthesia and have arranged transportation home after my appointment today. The person responsible for my transportation is:

I certify that I have explained the proposed anesthetic(s) to the patient, along with the risks, benefits and possible discomfort associated with them.