Healthcare Full SOMC

HEALTHCARE FULL SOMC

Patient Information

Patient Name:    Date of Birth:

Gender (check applicable): Male Female Other

Insurance Information

Medical History

Procedure / Services

Attending Provider:    Proposed Date of Service:

Consent for Treatment and Procedures

I, the undersigned patient or legal representative, authorize the licensed medical providers, their assistants, and other allied health personnel to perform the procedure(s) or treatment(s) described above and such additional procedures as may be necessary or advisable in the course of treatment. I acknowledge that no guarantees have been made concerning the results of treatment.

I have been informed of the nature and purpose of the proposed treatment and have had the opportunity to discuss expected benefits, material risks, common complications, and reasonable alternatives including the option of no treatment. Material risks may include, but are not limited to: infection, bleeding, scarring, reaction to medications or anesthesia, damage to adjacent structures, need for additional procedures, permanent impairment, or death.

I understand that unforeseen conditions may arise during the procedure necessitating additional and different procedures. I authorize the provider to perform any additional procedures that are, in the provider's judgment, necessary for my health and safety.

Alternatives to the proposed procedure, the risks of each alternative, and the risks of declining treatment have been explained to me. I have had the opportunity to ask questions and understand those answers.

Initial to indicate you have read and understand each item:

I understand the risks described above.
I understand the alternatives and risks of declining treatment.
I acknowledge the possibility of unforeseen conditions requiring additional procedures.

Anesthesia: I consent to administration of local, regional, or general anesthesia as deemed appropriate by the anesthesiologist or qualified provider. I understand anesthesia carries risks including allergic reaction, aspiration, respiratory or cardiac complications, and death.

Blood Products: I consent to transfusion of blood or blood products if medically necessary.

Advance Directives & Special Instructions

HIPAA Authorization and Privacy Acknowledgment

I authorize the use and disclosure of my protected health information as necessary for treatment, payment, and health care operations. I permit the providers to release medical records, diagnostic reports, and billing information to the persons and organizations responsible for payment and to other health care providers involved in my care. This authorization includes information regarding communicable diseases, mental health treatment, and treatment for substance use disorders to the extent permitted by law.

Purpose of Disclosure:    Expiration Date of Authorization:

I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization. I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights to restrict certain disclosures as allowed by law.

I acknowledge I have received and reviewed the Notice of Privacy Practices.

Authorization for Photography / Recording

Photographs, video, or audio recordings may be necessary for identification, treatment documentation, education, or quality assurance. I authorize use of such images for medical records. Use for publicity, marketing, or research requires separate written consent.

I consent to photography/video for medical record and treatment purposes only.

Patient Acknowledgment and Certification

I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that withholding relevant medical information may adversely affect my care.

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