Healthcare Orthopedic Patient Consent Form

Healthcare Orthopedic Patient Consent Form

Patient Information

Emergency Contact

Insurance Information

Medical History

Please indicate if any of the following apply:

History of bleeding disorder
Prior blood clots / deep vein thrombosis
Presence of pacemaker or implanted electronic device
Current tobacco use

Procedure and Anesthesia

I authorize the above-named surgeon and other qualified clinical personnel to perform the described procedure and any additional services that are necessary during the operative period. I understand that anesthesia may be administered, and that the anesthesiologist will obtain a separate consent for anesthetic care when appropriate.

Risks, Benefits and Alternatives

The risks and potential complications of orthopedic surgery include, but are not limited to: infection; bleeding; blood clots (deep venous thrombosis or pulmonary embolus); damage to nerves or blood vessels; persistent pain or stiffness; delayed healing, nonunion or malunion of bone; failure or loosening of implants or prostheses; need for additional surgery; allergic reaction to implants or medications; anesthesia-related complications; and, in rare instances, loss of limb or death. The anticipated benefits include relief of symptoms, improved function, and stabilization of the involved joint or bone.

Reasonable alternatives to the proposed treatment, including non-operative care, physical therapy, medications, injections, or delayed surgery, have been explained to me and I have had the opportunity to discuss these alternatives and ask questions.

I acknowledge that the risks, benefits, and alternatives have been explained and that I understand them.

Blood Products, Implants, and Specimens

If clinically necessary, I consent to the transfusion of blood products and derivatives. I understand that blood transfusion carries risks including transfusion reaction and infection. I understand that removed tissue and specimens may be sent for pathological examination and may be retained or disposed of in accordance with standard clinical practice.

I consent to blood transfusion if clinically necessary.
I consent to implantation of prosthetic devices, screws, plates, or other orthopedic implants if required.

Photography, Recording and Telemedicine

I authorize the taking of clinical photographs, video, or other images for purposes of medical record keeping, diagnosis, treatment planning, teaching, or quality improvement. Such images may be used in presentations or publications provided my identity is not disclosed without separate written authorization unless required for clinical care.

I consent to clinical photography and recording as described above.

HIPAA Authorization and Privacy

I understand that the providers will generate and maintain medical records related to my care. I hereby authorize the use and disclosure of my protected health information for purposes of treatment, payment and healthcare operations as permitted by law. I authorize release of medical information to the persons or entities involved in my care and to my insurance carrier for claims processing.

This authorization for release of information will remain in effect until revoked in writing. I understand that revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

I acknowledge receipt of a notice of privacy practices and authorize disclosure as described above.

Patient Rights and Certifications

I certify that I have read (or have had read to me) and understand the information in this document. All of my questions have been answered to my satisfaction. I understand that no guarantee has been made as to the results of the procedure. I understand that I may withdraw my consent at any time prior to the performance of the procedure by notifying the provider.

I authorize the named provider and designees to perform the procedure and to administer such medications, anesthetics and transfusions as may be necessary or advisable for my care. I consent to routine post-operative care and interventions associated with the described procedure.

I understand and agree to the statements above.

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