Healthcare Consent Acknowledgement

HEALTHCARE CONSENT ACKNOWLEDGEMENT

Provider/Facility:

Patient Information

Patient Name:   Date of Birth:   Gender:

Insurance Information

Medical History

Description of Procedure / Service

Proposed Date:   Estimated Duration:

Consent Terms and Acknowledgments

I hereby authorize the Provider/Facility named above and its designated health care practitioners to perform the procedure(s) described. I acknowledge that the nature, purpose, benefits, and material risks of the proposed procedure(s) have been explained to me in terms I understand, including but not limited to infection, bleeding, scarring, allergic reaction, complications requiring further surgery, prolonged recovery, temporary or permanent impairment, and death when applicable. I understand that no guarantee or assurance has been made as to the results that may be obtained.

Alternatives, expected benefits, and significant risks of not undergoing the procedure have been explained, and I have had the opportunity to ask questions and receive answers. I understand that I may withdraw consent at any time prior to the procedure but that withdrawal will not affect any actions already taken based on this consent.

Consent selections (check all that apply):

I consent to general medical and surgical care, examinations, tests, and treatment associated with the procedure.

I consent to the administration of anesthesia and related monitoring as deemed necessary by the anesthesia provider.

I consent to blood transfusions and blood products if deemed necessary in my care (unless I have indicated objection below).

I decline blood transfusions and blood products (understand that refusal may increase risk).

I consent to photographs, video, or audio recordings for medical documentation and treatment purposes. I understand any such recordings are part of my medical record.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or provided a copy of the Notice of Privacy Practices and understand that my protected health information may be used and disclosed for treatment, payment, and health care operations as described in that notice. I authorize the release of information necessary to process claims and to coordinate my care.

I acknowledge receipt of the Notice of Privacy Practices and consent to use and disclosure of my health information as described above.

Authorization to Release Medical Information

I authorize the Provider/Facility to release medical information related to the above procedure to: for the purpose of:

Patient Certification

By signing below I certify that I am the patient or the patient's legal representative and that I have read and understand the information on this form (or it has been read to me). I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives, and I voluntarily consent to the care, procedure(s), and uses/disclosures described above. I understand that additional procedures may become necessary during the course of treatment and I authorize such additional procedures if they are medically necessary.

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