Healthcare Patient Electronic Consent Form

HEALTHCARE PATIENT ELECTRONIC CONSENT FORM

Patient Name:    Date of Birth:    Medical Record No.:

Patient Information

Emergency Contact

Insurance Information

Medical History

Procedure / Service Consent

Procedure / Service to be performed:

Provider performing procedure:    Location:

I acknowledge that the nature, purpose, risks, and expected benefits of the procedure have been explained to me. Risks may include, depending on the procedure, but are not limited to: bleeding, infection, adverse reaction to medications, anesthesia complications, need for further procedures, and unforeseen complications. Benefits include diagnostic information and/or therapeutic effect as discussed with my provider. I understand that no guarantee has been made as to the results.

I understand I have the right to ask questions and to refuse or withdraw consent at any time prior to the procedure without jeopardizing future care. Withdrawal of consent may not apply to actions already taken in reliance on my consent.

For the purposes of this consent I authorize such diagnostic and therapeutic procedures as deemed necessary by the provider, including administration of medications and use of sedation or anesthesia if required.

I acknowledge that the risks and benefits were explained to me and I had an opportunity to ask questions.

I acknowledge that reasonable alternatives and their risks were discussed.

I understand there are no guarantees as to outcome.

Electronic Communication & Signature Consent

I consent to receive communications, notices, consent forms, and billing statements electronically, and I consent to the use of electronic signatures to document my consent. I understand that electronic communications may include email, secure patient portal messages, and SMS text messages where applicable. I may withdraw this consent at any time by written notice to the provider, but withdrawal will not affect actions already taken based on prior consent.

Email    SMS Text    Secure Patient Portal

HIPAA Authorization & Privacy Acknowledgement

I authorize the disclosure of my protected health information as necessary for treatment, payment, and healthcare operations, and to third parties designated in writing by me for the purpose of continuity of care. This authorization includes release of records related to the procedure, diagnostic testing, and related billing information. I understand that this authorization is voluntary and that my treatment will not be conditioned on signing this authorization, except where permitted by law.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by applicable privacy laws.

I acknowledge receipt of the facility's privacy practices and authorize release of my health information as described above.

Patient Certifications

By signing below I certify that I am the patient or I am authorized to sign on behalf of the patient. I certify that the information I have provided on this form is true and correct to the best of my knowledge. I further certify that I have read and understand this consent in its entirety, that the explanations provided to me were adequate, and that I give my informed consent for the treatment and disclosures described above.

I understand that electronic signature of this document shall have the same force and effect as a handwritten signature and shall be valid for all purposes.

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