Healthcare Adult Consent Form

HEALTHCARE ADULT CONSENT FORM

Facility and Provider Information

Patient Information

Patient Name:

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy/ID Number:    Group Number:

Medical History and Current Health

Do you use tobacco products? Yes No

Are you pregnant or suspect pregnancy? Yes No   If yes, estimated due date:

Procedure / Services to Be Provided

I acknowledge that the nature of the procedure, the expected benefits, material risks, possible complications, and reasonable alternatives have been explained to me in terms I understand. I have had the opportunity to ask questions and my questions have been answered to my satisfaction.

Consents and Authorizations

Consent to Treatment: I hereby authorize the Facility and the Provider, and such assistants as may be selected, to perform the procedure(s) and provide care as described above. I authorize the administration of such medications, anesthesia, and other medical services that may be necessary in the judgment of my treating providers.

Right to Withdraw: I understand that I may withdraw my consent at any time prior to the procedure by notifying the treating provider, unless withdrawal would jeopardize my health due to the timing of the procedure or treatment.

Consent to Anesthesia: If applicable, I consent to monitored anesthesia care, sedation, or general anesthesia as determined necessary by the anesthesiologist or qualified provider. I understand there are risks associated with anesthesia including allergic reactions, respiratory problems, and adverse effects.

Photography / Recording: I consent to clinical photography, video, or audio recording for medical, diagnostic, or educational purposes as necessary for my care. I understand that recordings used for education or publication will not include my identifying information without additional written permission.

Release of Records: I authorize the Facility to release pertinent medical information to insurance carriers, other healthcare providers, or as required by law in order to process claims or to coordinate my care.

Assignment of Benefits: I assign to the Facility and Provider any insurance or other third-party benefits payable for services rendered. I understand that I remain financially responsible for charges not covered by insurance or if payment is denied.

Student / Trainee Participation: I understand that students, residents, or other trainees may be present and participate in my care for educational purposes unless I refuse such participation.

HIPAA and Privacy Acknowledgement

I acknowledge receipt of the Facility's Notice of Privacy Practices which explains how my health information may be used and disclosed and how I can obtain access to this information. I authorize the Facility to use and disclose my protected health information for treatment, payment, and healthcare operations as described in the Notice.

I authorize disclosure of health information to the following persons (optional):

Attestations and Patient Certification

By signing below I certify that I am the patient or, if signing on behalf of the patient, that I am the legally authorized representative. I attest that I understand the information provided in this form, that the information I have provided is true and complete to the best of my knowledge, and that I consent to the care, procedures, and disclosures described herein.

I understand that unexpected findings or conditions may require additional or different procedures than those described, and I authorize the Provider to perform such additional procedures if, in the Provider's professional judgment, they are necessary for my health and safety.

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