Anaesthesia: Medical questionnaire

Please do not complete this part, as we will ask you to do so on the day of your admission.

If the aforementioned doctor is unable to fulfil their mandate, I consent to my care being provided by a different anaesthetist accredited by the clinic. I agree that the anaesthetic techniques used may be changed should it prove necessary for my care.
I have read and understood this document in full. I was given the opportunity to ask questions about the benefits and risks of the anaesthetic procedure at the pre-anaesthetic appointment and I understand the answers provided.

Applicable law
Any disputes that have arisen or arise in the future in connection with this agreement are subject to the exclusive jurisdiction of the Courts of Geneva. This agreement is governed by Swiss law. Prior consent to waive patient confidentiality
As part of my care, I consent to patient confidentiality being waived for the information required for the mandate holder to obtain their fees (the existence of the mandate, the anaesthetic administered, the number of hours invoiced, the applicable hourly rate and the degree of complexity of the anaesthetic), which may be sent to the Caisse des médecins (an administrative body for independent doctors in
Switzerland) for this purpose. I agree that, in the case of late payment, the data required to recover the payment may be sent by the accredited anaesthetist to the Office des poursuites et faillites (Office for Prosecutions and Bankruptcy) and /or the legal authorities, and, if applicable, the debt collection company InkassoMed. I can withdraw my consent at any time. I understand that if I do not provide my consent, the accredited anaesthetist can submit a request to their governing body (the Professional Confidentiality Commission in Geneva) for patient confidentiality to be waived, seek prosecution and launch legal proceedings.