Healthcare Medical Probe

HEALTHCARE MEDICAL PROBE CONSENT AND AUTHORIZATION

Patient Information

Date of birth:    Gender: Male   Female   Other

Insurance Information

Medical History

Procedure Description and Purpose

Procedure to be performed:

Physician performing procedure:

Risks, Benefits and Alternatives

The physician has explained the expected benefits, material risks, and reasonable alternatives. Significant risks associated with insertion of a medical probe include, but are not limited to:

• Bleeding; • Infection; • Local or systemic reaction; • Perforation of organ or tissue requiring further intervention; • Pain or discomfort; • Need for repeat procedure; • Adverse reaction to sedatives or anesthetic agents.

Alternatives explained include: continued medical management, imaging-based assessment, or delay of procedure to obtain further evaluation. I acknowledge that no guarantees were made concerning the outcome.

I have read or had read to me the risks and alternatives and I understand them.

Anesthesia / Sedation

Type of anesthesia/sedation planned:

None/local anesthetic   Conscious sedation   General anesthesia

I consent to administration of the indicated anesthesia and to such additional procedures as may be necessary for safe administration of anesthesia, including airway management and monitoring.

Specimens, Photography and Records

I authorize collection, testing, and disposal of specimens as necessary. I authorize photographs, video, or audio recordings for medical documentation and clinical care unless I mark otherwise below.

I consent to photographs/video for documentation of this procedure.

I do not consent to non-clinical use of photographs (e.g., teaching or publications) unless anonymized and additional consent obtained.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of a notice of privacy practices and authorize the disclosure of my protected health information to those individuals involved in my care and as required for billing and regulatory purposes.

I acknowledge that I have been provided the privacy notice and consent to uses and disclosures described therein.

Authorization and Duration

I authorize the performance of the procedure described above and related care, including provision of emergency treatment if required. This authorization is effective immediately and will remain in effect until revoked in writing or until:

I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization.

Certification and Patient Statement

By signing below I certify that I have read (or this has been read to me) and understand this consent form. I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I understand the nature, risks, benefits and alternatives to the procedure and consent to proceed.

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge.

Sign Now