Healthcare Preoperative Booklet

HEALTHCARE PREOPERATIVE BOOKLET

Patient Information

Patient Name:

Date of Birth:   Gender:

Procedure and Provider Information

Procedure:

Primary Surgeon:   Facility:

Scheduled Date:   Pre-Op Arrival Time:

Insurance and Financial Responsibility

Medical History and Current Status

Do you use tobacco, alcohol, or recreational drugs? Tobacco Alcohol Recreational drugs

Preoperative Instructions (Acknowledgment)

The following are standard preoperative instructions. Please confirm you have received and understand these instructions by checking the confirmation box and providing requested information.

• Do not eat or drink after the time indicated by your provider. Exceptions are specified by your provider.
• Take or withhold medications as instructed. Bring a list of medications to pre-op.
• Bring photo identification and insurance card(s) to arrival.
• Arrange for responsible adult to transport you home and stay with you for 24 hours if required.

Confirm fasting since:   Last oral intake (what & when):

I acknowledge I have received, read, and understand the preoperative instructions and have had the opportunity to ask questions.

Consent for Procedure and Anesthesia

By signing below I authorize the attending surgeon, assistants, anesthesiologist, and other authorized clinical personnel to perform the procedure identified above, including any additional procedures that, in the professional judgment of the surgeon, are necessary or advisable for my well-being. I understand the procedure may include use of devices, implants, or blood products as clinically indicated.

I acknowledge that the risks, benefits, and reasonable alternatives (including non-operative management) were explained to me, and I had an opportunity to ask questions. I understand risks include, but are not limited to, infection, bleeding, anesthetic complications, pain, scarring, organ or nerve injury, and need for further surgery. No guarantee or assurance has been made to me concerning the results of the procedure.

Consent for anesthesia: I consent to the administration of local, regional, or general anesthesia as determined necessary by the anesthesia provider. I understand anesthesia carries risks including allergic reactions, respiratory or cardiac complications, and, rarely, death.

Consent for blood products: I consent to receive blood or blood products if deemed medically necessary in the event of significant blood loss. If I refuse blood products, I understand other measures will be taken and that refusal may limit treatment options.

I understand I may withdraw this consent at any time prior to the procedure by notifying the provider, except in circumstances where withdrawal would create immediate danger to my health.

Preoperative Checklist (To be completed with staff)

Pre-op testing completed: Lab work ECG Imaging

Implant or device to be used (if applicable):

HIPAA Privacy Acknowledgment and Authorization

I acknowledge that I have been offered a copy of the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize release of my medical information, including records of this procedure and related billing information, to my insurance carrier(s) and to the following persons for scheduling and post-operative care:

This authorization to release information will expire on:

I understand that I may revoke this authorization in writing at any time except to the extent action has already been taken in reliance on it.

Patient Rights and Financial Consent

I accept financial responsibility for charges not covered by my insurance and authorize my provider to submit claims on my behalf. I authorize payment of benefits to the provider for services rendered. I understand I am responsible for co-payments, deductibles, and non-covered services.

Emergency contact for postoperative questions:   Phone:

Declaration

I declare that the information provided in this booklet is true and complete to the best of my knowledge. I have had the opportunity to ask questions and these have been answered to my satisfaction. I understand the nature of the proposed treatment and accept the risks described above.

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