Healthcare Medical Surgical HWS

Healthcare Medical Surgical HWS

Patient Information

Patient Name:

Emergency Contact

Insurance Information

Medical History & Current Status

Do you take blood thinners or anticoagulants? Yes No

Are you pregnant, trying to become pregnant, or breastfeeding? Yes No

Procedure Information & Surgical Consent

Scheduled Procedure Date:

General anesthesia Regional / Spinal Local / Sedation Other

Risks, Benefits, Alternatives

I acknowledge that the proposed procedure and associated anesthesia have been explained to me, including the anticipated benefits, material risks, and reasonably available alternatives. Material risks may include, without limitation, infection, bleeding, need for transfusion, allergic reaction, damage to adjacent structures, anesthetic complications, need for additional procedures, prolonged recovery, permanent impairment, or death. The list above is not exhaustive; other risks specific to my condition or procedure may exist and have been discussed as applicable.

Alternatives to the proposed procedure, including non-surgical options, have been discussed with me including the risks and benefits of those alternatives and the risks of no treatment.

Authorizations & Acknowledgements

By signing below I authorize the physician, assistants, anesthetists, nursing staff, and other health care providers to perform the procedure described above and to provide such care, including administration of anesthesia, injections, medications and blood products as are necessary or advisable in the professional judgment of the treating providers.

I authorize the use, disposal, or examination of any tissue or specimens removed during the procedure for diagnostic purposes and hereby consent to photographs or recordings as deemed necessary for medical or educational purposes, provided that confidentiality is maintained.

I acknowledge financial responsibility for services rendered and authorize the release of medical information to insurance carriers, workers' compensation, or other third-party payers for claims administration and payment. This authorization includes disclosures necessary for claims processing and quality assurance.

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing my rights with respect to protected health information and how such information may be used and disclosed. I consent to the use and disclosure of my health information for treatment, payment, and health care operations as described in that notice.

Authorization Expiration Date:

Patient Certifications

I certify that the information I have provided on this form is accurate to the best of my knowledge. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I understand that I may revoke this consent at any time orally or in writing prior to the procedure, except to the extent that action has already been taken in reliance upon this consent.

I understand that unforeseen conditions may necessitate additional or different procedures than those listed above, and I authorize the provider to perform such additional procedures as are necessary in the professional judgment of the treating team.

I have been informed of and understand preoperative and postoperative instructions, including restrictions on driving, activity, medications, and follow-up appointments, and agree to comply with the recommended care plan.

Sign Now