Healthcare Operation Kids Sight Form

Healthcare Operation Kids Sight Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Non-binary Prefer not to say

Insurance Information

Medical & Vision History

Vision history: Wears glasses or contact lenses? Yes No    History of amblyopia (lazy eye)? Yes No

Planned Procedure & Consent

Procedure to be performed:

Surgeon:    Expected date of procedure:

I authorize the recommended procedure and related diagnostic or therapeutic services. I understand the nature and purpose of the procedure, its intended benefits, and that no outcome can be guaranteed. I acknowledge that the physician has explained the following risks specific to pediatric ocular surgery, which may include but are not limited to: infection, bleeding, anesthetic complications, persistent diplopia, decreased vision, need for additional surgery, scarring, corneal or retinal injury, loss of sight, and unforeseen complications that could be permanent. I acknowledge that these risks have been explained and I have had an opportunity to ask questions.

I understand that I may withdraw consent at any time prior to the procedure without penalty, and that withdrawal may require discussion of alternatives and potential consequences. If the patient is a minor, the legal guardian signing below gives consent on behalf of the minor patient.

Anesthesia, Photography & Records

I consent to the administration of local or general anesthesia as required for the procedure. I acknowledge that anesthetic risks include allergic reaction, breathing problems, cardiac events, and, rarely, death. I authorize the anesthesiologist to perform procedures deemed necessary in the event of an emergency.

I consent to intraoperative and clinical photography, videography, or imaging for medical documentation, teaching, and quality assurance purposes. I understand that identifying information will be protected in accordance with privacy policies and that photographs used for teaching or publication will be de-identified unless I provide separate written authorization.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the practice's privacy notice and authorize release of medical information necessary for treatment, payment, or healthcare operations. I authorize the release of my child's medical records to other treating providers as needed for continuity of care. This authorization does not apply to psychotherapy notes and may be revoked in writing at any time except to the extent action has already been taken in reliance on this authorization.

Financial Responsibility & Assignment

I authorize billing of my insurance benefits for services rendered and assign benefits payable for medical services to the treating provider. I accept financial responsibility for charges not covered by insurance. I understand that estimates are not guarantees of payment and that I remain responsible for any balance.

Pre-Procedure Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I agree to notify the surgical team promptly of any changes in health, medications, or allergies prior to the procedure.

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