Healthcare Pre-Operational Release

Healthcare Pre-Operational Release

Patient Information

Patient Name:     Date of Birth:     Gender:

Emergency Contact

Insurance Information

Medical History

Do you have a history of bleeding disorders or are you on blood thinners? Yes No

Are you pregnant or breastfeeding? Yes No

Planned Procedure and Assessment

Scheduled Procedure Date:     Facility / Location:

Risks, Benefits & Alternatives

The clinician has explained the nature and purpose of the proposed procedure, the expected benefits, material risks, and reasonable alternatives including the risks of not proceeding. Typical risks include, but are not limited to: infection, bleeding, scarring, allergic reaction, need for additional procedures, adverse reaction to anesthesia or sedation, and unsatisfactory outcome. Unpredictable complications may occur.

I acknowledge that no guarantees or assurances have been made to me regarding the results of the procedure.

I understand the available alternative treatments (including refusal) and their associated risks and benefits. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Authorizations and Releases

By signing below I authorize the performance of the above-described procedure by the authorized clinical staff. This authorization includes administration of local or general anesthesia, necessary diagnostic tests, and any additional procedures arising from unforeseen conditions that, in the judgment of the treating clinician, are necessary for my safe care.

I authorize release of my protected health information to other healthcare providers, health insurers, and persons designated by me as necessary to carry out treatment, payment, or healthcare operations. I authorize the facility and practitioners to dispose of tissue or specimens removed as part of the procedure in accordance with applicable standards.

I release and hold harmless the facility, its clinicians, employees and agents from liability for ordinary negligence in connection with the performance of the procedure, except as prohibited by law. I agree to indemnify the facility for claims arising from my failure to disclose material medical history or from my noncompliance with pre- or post-operative instructions.

I consent to photographs, video, or other images for clinical documentation, quality assurance, or education. I understand identifying information will be protected in accordance with applicable privacy policies unless I authorize broader use.

I consent to clinical photography/videography. I do not consent to photography/videography.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a notice of privacy practices describing how my protected health information may be used and disclosed and how I may obtain access to this information. I authorize disclosure of my health information to individuals I designate for purposes related to my care and billing.

Pre-Operative Instructions Acknowledgment

I attest that I have received pre-operative instructions including fasting, medication adjustments, arrival time, and transportation arrangements. I understand that failure to follow instructions may result in delay or cancellation.

I have received and understand the pre-operative instructions.

Patient Rights and Withdrawal

I understand that I have the right to refuse or withdraw consent at any time prior to the initiation of the procedure. Withdrawal of consent after initiation of the procedure may not be possible and may create medical risk. If I withdraw consent prior to procedure, I must notify the facility as soon as practicable.

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