Healthcare Pre-Op Packet

HEALTHCARE PRE-OP PACKET

Patient Information

Emergency Contact

Insurance Information

Medical History

Penicillin Sulfa Latex Peanuts Other

Diabetes Hypertension Heart disease Respiratory disease Bleeding disorder

Pre-Operative Instructions & Acknowledgment

I acknowledge that I have received and understand the pre-operative instructions provided by the surgical team, including required fasting, medication guidance, and arrival time. I understand failure to follow instructions may result in cancellation of the procedure.

Fasting instructions: No solid food for hours prior to the scheduled procedure. Clear liquids permitted until .

Medication instructions: I will take or withhold medications as instructed. If applicable, I will bring a list of my medications and the bottles to pre-op.

Acknowledgement: I have read and understand the pre-operative instructions.

Consent for Anesthesia and Surgical Procedure

Patient Name:

Procedure to be performed:

I authorize the attending surgeon, assistants, anesthesia provider and other clinical staff to perform the above procedure and any additional procedures which, in the opinion of the surgeon, are necessary or advisable in the course of the operation. I authorize administration of anesthesia as deemed appropriate.

Risks and complications, which may be serious and include but are not limited to infection, bleeding, adverse reaction to anesthesia, blood clots, organ injury, scarring, persistent pain, neurological injury, and in rare cases permanent disability or death, have been explained to me. I acknowledge that no guarantees or promises have been made with respect to the results of the procedure.

Alternatives to the proposed procedure, including non-surgical options, have been explained and I have had the opportunity to ask questions. I understand I may withdraw consent at any time prior to the procedure.

Consent to blood products: I consent to transfusion of blood products if deemed necessary by my care team.

HIPAA Privacy & Release

I acknowledge receipt of the facility's Notice of Privacy Practices and understand my rights regarding protected health information. I authorize the release of my medical information necessary for treatment, payment, and healthcare operations and specifically permit release to my emergency contact listed above.

Authorization to share information with emergency contact: I authorize disclosure of relevant health information to the person listed as my emergency contact.

Authorization & Expiration

I hereby authorize the individuals and entities described above to perform the authorized care, release information as necessary, and bill insurance and myself as appropriate. This authorization expires on:

Patient Statement

I certify that the information I have provided on this pre-operative packet is true and complete to the best of my knowledge. I understand the nature of the planned procedure and associated risks, and I have had opportunity to ask questions which were answered to my satisfaction.

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