Healthcare Medical Sur Certificate

HEALTHCARE MEDICAL SUR CERTIFICATE

This Medical/Surgical Certificate documents the patient's medical information, acknowledgement of risks, and informed consent required prior to a scheduled medical or surgical procedure. Completion of this form certifies that the patient (or authorized guardian) has received a description of the proposed procedure, understands the risks and alternatives, and authorizes the provision of medical care as described below.

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Procedure Details

Proposed Procedure:

Proposed Date:    Facility:

Attending Surgeon:    Estimated Length of Stay:

Anesthesia Plan: Local Regional General Other

Risks, Benefits, and Alternatives

The patient acknowledges that the attending clinician has explained the nature of the proposed procedure, the anticipated benefits, the reasonably foreseeable risks and complications (including but not limited to infection, bleeding, anesthesia-related events, adverse reactions, and the possibility of additional procedures), and reasonable alternatives including non-surgical options. The patient further understands that no guarantees have been made regarding the outcome.

I acknowledge that the risks, benefits, and alternatives were explained to me and I have had the opportunity to ask questions and receive answers to my satisfaction:

Consent, Authorizations, and Certifications

By signing this certificate I certify that I am the patient named above (or the legally authorized representative of the patient). I consent to the performance of the procedure described herein and to any additional procedures or modifications that may be necessary in the professional judgment of the attending clinician to provide safe and effective care. I authorize administration of anesthesia and any medications deemed necessary, including blood products if required in an emergency.

I understand I have the right to refuse the procedure and the right to withdraw my consent at any time prior to the administration of anesthesia or performance of the procedure. I authorize the release of medical records related to this procedure to other healthcare providers and insurers for treatment, payment, or healthcare operations as required to facilitate my care.

I specifically authorize (initial applicable): Blood products if required Clinical photography for documentation

This authorization for treatment and release of records expires on:

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered access to the healthcare provider's privacy practices regarding my protected health information and that I understand my rights regarding privacy and disclosure of medical information as it relates to the treatment and billing for the procedure.

I acknowledge receipt of privacy information:

Additional Administrative Information

Certification and Signature

I certify under penalty of perjury under the laws applicable to medical documentation that the information provided on this Medical Sur Certificate is true and correct to the best of my knowledge, and that I have been afforded the opportunity to ask questions and have those questions answered satisfactorily.

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