I hereby authorize and direct Barry L. Friedberg, M.D., a Board Certified anesthesiologist, to administer intravenous sedation (M.A.C.) or general anesthesia for surgery. I understand the anesthesiologist will choose the type of anesthesia which he believes, in his professional opinion, is the safest and most effective. I further understand that the type of anesthesia may be altered from that which was discussed by the anesthesiologist for the safety and well being of the patient.

I understand that although favorable results can be expected, they cannot be and are not guaranteed. There is no guarantee against poor results or complications, either, expressed or implied.

It is the understanding of the patient or the patient's medical legal representative that the anesthesiologist will have full charge of the administration and maintenance of the anesthesia. I know that anesthesia, by an anesthesiologist, is an independent function apart aside from surgery. As such, anesthesia is not part of surgery when it is administered by an anesthesiologist. Because of this, an adverse result from a surgical procedure is not to be an adverse result from the anesthesia.

I agree to pay all fees related to the anesthesia services, apart from surgery fees.

PATIENT SIGNATURE __________________________________

DATE ________________________ & TIME _____________(A.M.) (P.M.)

When a patient is a minor or incompetent to give own consent, signature of person authorized to give consent:

WITNESS ___________________________   DATE ___________________