Healthcare PreOp Bind Form

Healthcare PreOp Bind Form

Patient Information

Insurance & Billing

Planned Procedure & Provider

Surgeon / Provider:    Facility:

Planned Procedure:

Scheduled Date:    Expected Anesthesia: General Regional Local Conscious Sedation

Medical History

History of bleeding disorder or abnormal clotting tests? Yes No

For persons of childbearing potential: Are you pregnant or breastfeeding? Yes No

Preoperative Consents

By signing below, I authorize the above-named surgeon and such assistants as may be selected to perform the procedure described above and any additional procedure(s) which, in the opinion of the surgeon or anesthesiologist, may be necessary or advisable during the operative period. I understand that medicine and surgery are not exact sciences and that no promises or guarantees have been made to me regarding outcome.

I consent to administration of anesthesia and related care by the anesthesia provider and acknowledge that anesthesia involves risks including but not limited to allergic reaction, nausea, aspiration, dental or nerve injury, cardiovascular complications, respiratory complications, stroke, coma, and death. I understand specific risks vary by procedure and by my medical condition.

I acknowledge the risks of the procedure include infection, bleeding, scarring, failure to achieve the desired result, need for additional procedures, injury to adjacent organs or structures, and potential for permanent impairment. The foregoing list is not exhaustive; the provider has discussed risks, benefits, and alternatives with me and I have had the opportunity to ask questions.

I consent to the receipt of blood products if deemed medically necessary. I understand blood transfusion involves risks including transfusion reaction and infection. I choose to: Consent Refuse

I grant permission for photographs, video, or other images to be taken for medical record, diagnostic, or educational purposes and understand identifying information will be protected as required by law unless I indicate otherwise in writing.

I understand I retain the right to withdraw consent at any time prior to administration of anesthesia or induction of the procedure. Withdrawal after anesthesia has begun may not be medically feasible without increased risk.

Financial Responsibility & Acknowledgments

I acknowledge financial responsibility for charges not covered by insurance, including deductibles, co-insurance, and non-covered services. I authorize the release of medical information necessary to process insurance claims and certify the information I have provided is true and correct to the best of my knowledge.

Cancellation / No-Show: I understand that failure to appear or last-minute cancellation may result in a cancellation fee and that scheduling or rescheduling fees may apply per facility policy.

HIPAA Acknowledgment & Release of Information

I acknowledge I have been provided with the facility's Notice of Privacy Practices and that protected health information may be used or disclosed for treatment, payment, and health care operations. I authorize the use and disclosure of my medical information to my insurance company, referring physician, family members identified below, and other providers involved in my care as necessary.

Patient Certification

I certify that I have read (or have had read to me) this form in a language I understand. I have had the procedure, risks, benefits, alternatives, and expected recovery explained to me and have had the opportunity to ask questions. I understand the nature and purpose of the procedure and consent to it and to the administration of anesthesia as necessary.

I certify that the medical and insurance information I have provided is accurate and complete. I understand that misrepresentation may affect my care and billing. I accept financial responsibility as stated above.

Sign Now