Healthcare Pre-op Document

HEALTHCARE PRE-OP DOCUMENT

Patient Information

Insurance Information

Medical History

Have you ever had an adverse reaction to anesthesia?   Yes   No

Pre-Operative Checklist

I confirm that I have received and understand pre-operative instructions, including fasting requirements:

I have fasted as instructed (no food or drink unless instructed otherwise)

I may be pregnant or am uncertain about pregnancy

I have an implanted medical device (pacemaker, defibrillator, neurostimulator) — provide details:

Planned Procedure and Providers

Procedure to be performed:

Primary Surgeon / Proceduralist:

Proposed Date of Procedure:

Anesthesia

I consent to the administration of anesthesia as recommended by the anesthesia provider. I understand that the anesthesia team will determine the appropriate anesthetic plan. Types of anesthesia that may be used (check all that apply):

General anesthesia   Regional (spinal, epidural, nerve block)   Local anesthesia   Conscious sedation / MAC

Risks, Benefits and Alternatives

The recommended procedure and anesthesia have been explained to me, including expected benefits, material risks, and reasonable alternatives including non-operative treatment and the option of no treatment. I understand that no guarantee can be made as to outcome. Material risks include, but are not limited to: infection, bleeding, blood clots, damage to nerves or other organs, need for additional procedures, poor wound healing, anesthetic complications including allergic reaction, respiratory or cardiac complications, permanent disability, and death.

I acknowledge that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction. I understand that I may withdraw my consent at any time before the procedure without affecting my right to future care.

HIPAA / Privacy & Authorization

By signing this document I acknowledge receipt of the facility's privacy practices and authorize the use and disclosure of my protected health information for treatment, payment and health care operations as necessary for my care and related administrative activities. I authorize release of information to my insurer and agents for billing and payment purposes.

This authorization expires on:

I acknowledge receipt of the privacy notice and authorize disclosure as stated above.

Additional Authorizations

I consent to administration of blood and blood products if deemed necessary by my physicians.

I authorize disposal of excised tissue in accordance with facility policy.

I consent to clinical photography for medical records, education, and quality improvement (identity will be protected unless separate written authorization is obtained). If yes, optional purpose/details:

Patient Certification

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand the planned procedure, potential risks and benefits, and alternative treatments. I consent to the performance of the procedure and administration of anesthesia as described above by the named provider(s) and those they designate. I understand that circumstances may require additional or different procedures than those described and I authorize the provider to perform such additional procedures as are medically necessary.

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