I, the undersigned, do hereby state and confirm as follows:

I have been explained the following in terms and language that I understand. I have been explained the following in {{LANGUAGE}} (name of the language or dialect) that is spoken and understood by me.
I have been explained; I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named principal anesthetist and his / her team with associates or assistants of his / her choice to induce anesthesia mentioned herein above during the course of the proposed intervention / procedure / surgery and also to administer the requisite drugs and medications.
I have been explained and have understood the importance of preoperative fasting and the risks of consuming solids / liquids prior to the induction of anesthesia.
I have been explained and have understood that inducing anesthesia has certain material risks / complications and I have been provided with the requisite information about the same. I have also been explained and have understood that there are other undefined, unanticipated, unexplainable risks / complications that may occur during or after inducing anesthesia.
I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.