Healthcare Patient Surgery Center Document

PATIENT SURGERY CENTER CONSENT AND ADMISSION FORM

Patient Information

Date of Birth:    Gender: Male Female Other/Prefer not to say

Insurance and Billing

Subscriber Date of Birth:

Medical History

History of bleeding disorder or easy bleeding: Yes No    Prior adverse reaction to anesthesia: Yes No

Pre-Operative Assessment

Height:    Weight:

Last solid food or non-clear liquids:    Last clear liquids:

Tobacco use within last 30 days: Yes No

Planned Procedure / Consent for Treatment

Scheduled Procedure Date:

Consent for Procedure and Anesthesia

I authorize the surgeon, anesthesiologist and other qualified clinical personnel to perform the above-described procedure and any additional procedures which, in the opinion of the surgeon, are necessary or advisable for proper care. I understand and acknowledge that no guarantee has been made as to the results of the procedure.

I understand the common and significant risks and complications include but are not limited to: infection, bleeding, scarring, injury to nearby structures, need for additional surgery, anesthesia complications including allergic reaction, respiratory or cardiac events, and death. I understand that unforeseen conditions may make necessary additional or different procedures than those described above.

I have had the opportunity to discuss the procedure, expected benefits, potential risks, and reasonable alternatives (including non-operative management) with my surgeon and/or the surgical team. I understand I may withdraw consent at any time prior to the administration of anesthesia or the initiation of the procedure.

Type of anesthesia planned (select all that apply): Local Regional General Monitored Sedation

Consent for Blood Products: I consent to the administration of blood, blood products, or blood derivatives if deemed necessary by the treating physician to treat life-threatening blood loss or other conditions. Yes No

Authorization, Assignment and Release

I authorize the facility and provider to perform the procedures and treatments described above and to release medical information to my insurer and other health care providers as needed for payment and continuity of care. I authorize payment of insurance benefits directly to the facility and provider. I accept financial responsibility for charges not covered by insurance or other third-party payers.

I authorize release of photographs, video or other images taken for medical or quality assurance purposes and understand such images will be used only for treatment, education, quality assurance or legitimate business purposes unless additional written authorization is obtained.

HIPAA Acknowledgment

I acknowledge that I have been provided an opportunity to receive the facility's Notice of Privacy Practices which describes how my protected health information may be used and disclosed. I consent to the use and disclosure of my protected health information for treatment, payment and health care operations, including electronic exchange as required for billing and claims adjudication.

Patient communications and appointment reminders may be sent by phone, voicemail, text message, or email to the contact information provided unless I indicate otherwise below. I do not consent to electronic reminders

Pre-Procedure Instructions Acknowledgment

I confirm that I have received and understand the pre-operative instructions, including fasting, medication guidance, arrival time and arrangements for post-procedure transportation and care. I understand that failure to follow instructions may result in cancellation or postponement of the procedure.

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