Healthcare Informed Consent Waiver

HEALTHCARE INFORMED CONSENT WAIVER

Patient Name:   Date of Birth:

Patient Information

Insurance Information

Medical History

Procedure, Risks, Benefits and Alternatives

Procedure to be performed:   Scheduled Date:

I acknowledge that the treating clinician has explained the nature and purpose of the proposed procedure, the material risks and potential complications (including but not limited to infection, bleeding, scarring, adverse reaction to medications or anesthesia, permanent impairment, and death), the probable benefits, reasonable alternatives including no treatment, and the likely results if the procedure is not performed. I further acknowledge that no guarantee or warranty has been made to me regarding outcome.

I have been informed of reasonable alternatives to the proposed procedure and the risks and benefits of those alternatives. My questions have been answered to my satisfaction.

Acknowledgements:

I understand the risks, benefits, and alternatives described above.
My questions have been answered in terms I understand.
I understand that no guarantee has been made regarding the outcome of the procedure.

Anesthesia, Blood and Specimens

The following limited authorizations are requested as applicable to the planned procedure:

Consent to local anesthesia or sedation as clinically indicated.
Consent to general anesthesia if deemed necessary by the provider and anesthesiologist.
Consent to blood transfusion if required to preserve life or health.
Consent to clinical photographs, tissue or fluid specimens for diagnosis, treatment, and medical records.

Voluntary Consent and Waiver

I voluntarily consent to the performance of the procedure described above by the provider and such assistants as are deemed necessary. I understand I may withdraw this consent at any time prior to the procedure without penalty and that withdrawal will not affect my rights regarding future care.

By signing below I expressly authorize the release of the treating clinician, the facility, and their employees and agents from liability for complications that may arise from the risks described above, except to the extent caused by gross negligence or willful misconduct. This waiver does not relinquish any rights or remedies for malpractice that are recognized by law where the standard of care has not been met.

Consent affirmation:

I voluntarily consent to the procedure and I understand the contents of this form.

Privacy and Release of Information (HIPAA Acknowledgment)

I acknowledge that I have been provided with or offered the facility's Notice of Privacy Practices describing how my medical information may be used and disclosed. I authorize the release of my medical information to my insurer and other healthcare providers as necessary for treatment, payment, and healthcare operations related to the procedure.

I acknowledge the privacy notice and authorize release of information as described above.

Authorization Term

This authorization shall remain in effect until: or until revoked in writing by the patient.

Patient Certification

I certify that I have read (or had read to me) this consent and that the information contained herein is true and correct to the best of my knowledge. I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I understand the risks, benefits and alternatives and I hereby authorize the persons named above to perform the procedure and any reasonably necessary related treatment.

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