Healthcare Orthopedic Document

HEALTHCARE ORTHOPEDIC CONSENT AND PATIENT HISTORY

Patient Information

Date of Birth:    Gender: Male  Female  Other 

Insurance Information

Subscriber Date of Birth:

Medical History & Current Status

Height:    Weight:

Do you smoke or use tobacco products? Yes  No  If yes, amount per day:

For persons assigned female at birth: Are you pregnant or breastfeeding? Yes  No

Procedure Description & Consent

I hereby authorize the physician and such assistants as may be selected to perform the procedure(s) described above and perform such additional procedures as are necessary and advisable in the event of an unexpected condition. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

The following risks and complications have been explained to me and I understand they may include, but are not limited to: infection, bleeding, blood clots (deep venous thrombosis and pulmonary embolism), nerve injury, vascular injury, delayed or non-union of bone, persistent pain or stiffness, implant failure or loosening, need for additional surgery, adverse reaction to implants or grafts, anesthetic complications, and death. I understand the relative frequency and potential consequences of these risks as they apply to my condition.

Alternatives to the proposed procedure, including non-surgical treatments, physical therapy, injections, and no treatment, have been explained. I have had the opportunity to ask questions regarding the nature, expected benefits, material risks, and alternatives and have received answers to my satisfaction. I understand I may withdraw this consent at any time prior to the start of the procedure.

I consent to the administration of anesthesia as deemed appropriate by the anesthesia provider. I authorize the administration of blood products if deemed necessary in the course of treatment, and I understand the risks associated with transfusion.

Privacy, Authorization & Release

I authorize the release of my medical records, imaging, and operative reports to my insurance carrier and to other health care providers for treatment, payment, and health care operations related to the care provided for the above condition. I understand this authorization includes but is not limited to: diagnostic information, operative findings, implant details, and photographs or video taken for medical documentation.

I acknowledge receipt of the Notice of Privacy Practices describing how my medical information may be used and disclosed and my rights regarding such information. I consent to communication of appointment reminders and treatment information to the phone and email listed above.

Interpreter required? Yes  If yes, language:

Acknowledgment and Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I have had an opportunity to ask questions and understand the nature and purpose of the proposed procedure, foreseeable risks, benefits and alternatives. I authorize the named provider(s) to perform the procedure(s) described and such other procedures as may be necessary in the course of care. I acknowledge that no guarantees regarding outcome have been made.

I also authorize the release of billing information to my insurance carrier and assign benefits where permitted. I understand that I am financially responsible for charges not covered by insurance.

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