Healthcare Grafting Consent Form

HEALTHCARE GRAFTING CONSENT FORM

Patient Information

Patient Name:

Insurance Information

Medical History

Are you pregnant or breastfeeding?

Procedure Information

Procedure to be performed:

Anatomic site(s):

Autograft (your own tissue)   Allograft (donor human tissue)   Xenograft (animal-derived)   Synthetic/biomaterial

Planned anesthesia:

Risks, Benefits, and Alternatives

I acknowledge that the proposed grafting procedure, its associated anesthesia, and related care have been explained to me. The clinician has described the anticipated benefits, the nature of the procedure, and the material to be used. I understand that complications may occur. Common and serious risks include, but are not limited to:

• Infection at donor or recipient site
• Bleeding or hematoma formation
• Graft failure, partial or complete loss of graft
• Scarring, contour irregularity, or poor cosmetic result
• Nerve injury with numbness or weakness
• Allergic reaction to graft material or medications
• Need for additional procedures or revisions
• Anesthesia-related complications, including systemic effects

I have been informed of reasonable alternatives to this procedure, including non-operative management and the option of no treatment. Alternatives discussed:

Infection   Bleeding   Graft failure   Scarring

Nerve injury   Allergic reaction   Anesthesia risks   Possible need for additional surgery

Consent for Use of Donor Tissue, Tests, and Photographs

If donor human tissue, allograft, or biologic material is used, I understand that such material may be tested, processed, or discarded according to applicable medical standards. I consent to the use of the following as indicated:

Use of donor human tissue/allograft as part of the procedure

Use of synthetic or processed biomaterials

Permission to take clinical photographs for the medical record, treatment planning, quality assurance, or education (identifying information will be protected)

Patient Rights and Other Authorizations

I understand that I have the right to ask questions and to refuse or withdraw consent at any time prior to the procedure without affecting my right to future care or treatment. I acknowledge that withdrawal of consent after administration of anesthesia or performance of the procedure may not be possible without risk and that I will discuss concerns with the clinical team.

I authorize the clinical team to perform any additional procedures that, in the clinician's professional judgment, are necessary due to unforeseen findings during the procedure.

I understand that I am financially responsible for charges not covered by my insurance. The facility and treating clinicians may bill my insurance carrier and I authorize release of medical information necessary for payment and treatment.

I acknowledge that I have received or been offered the facility's notice of privacy practices and that my health information may be used for treatment, payment, and healthcare operations as allowed by law.

Authorization expiration date:

Patient Certification and Signature

By signing below I certify that I have read and understand this consent form, that all my questions have been answered to my satisfaction, that I consent to the proposed grafting procedure and associated care described above, and that I authorize the named providers to perform the procedure and treatments as indicated.

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