Healthcare Consent Questionnaire

HEALTHCARE CONSENT QUESTIONNAIRE

Patient Information

Date of Birth:    Gender: Male   Female   Non-binary   Prefer not to disclose

Insurance Information

Medical History

Penicillin   Peanuts/Tree nuts   Latex   Eggs   Other

Procedure / Consent Details

I have been informed about the nature and purpose of the proposed procedure, including the expected benefits, material risks and potential complications, and reasonable alternatives. I acknowledge that no guarantee has been made as to the results of the procedure. By checking the boxes below I attest that these topics were explained and I understand them:

I understand the material risks, complications, and potential side effects associated with the procedure.
I have been informed of reasonable alternatives to the proposed procedure, including no treatment.
I understand the anticipated benefits and probable outcome of the procedure.
I consent to administration of anesthesia or sedation if determined necessary by the treating clinician.
I consent to clinical photography or video recording for medical documentation and treatment purposes (identifying information will be protected).

HIPAA / Privacy Authorization

I have received or been offered a notice describing how my protected health information may be used and disclosed and how I can obtain access to this information. I authorize the release of my medical and billing records as necessary for treatment, payment, and health care operations. I understand that I may revoke this authorization in writing except to the extent actions have already been taken in reliance upon it.

I acknowledge the privacy practices described above and consent to use and disclosure of my protected health information as stated.

Authorization Period & Revocation

This authorization is effective immediately and will expire on:   or upon completion of the described procedure and related follow-up care, whichever occurs later. I understand I may revoke this authorization in writing, except to the extent that the practice has already taken action in reliance on it.

Additional Authorizations

I authorize release of medical records related to this care to the following person(s) or entity(ies):

Financial Responsibility: I acknowledge responsibility for charges not covered by insurance. In an emergency, I consent to necessary treatment to preserve life or prevent harm.

Attestation and Certification

By signing below I certify that I have read and fully understand this Healthcare Consent Questionnaire. I affirm that the information I have provided is true and complete to the best of my knowledge. I voluntarily authorize the performance of the procedure and related care as described above and consent to the uses and disclosures of my health information as stated.

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