Healthcare Prep Document

HEALTHCARE PREPARATION AND AUTHORIZATION DOCUMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Allergies: Drug Food Latex Other

Are you pregnant or might be pregnant? Yes No

Pre-Procedure Preparation

I acknowledge I have received and understand the pre-procedure instructions regarding fasting, medication adjustments, arrival time, and post-procedure care. I confirm the following (check all that apply):

I have fasted for the required period described by clinical staff.
I have followed instructions regarding taking or withholding medications.
I will arrive at the scheduled time and arrange transportation if required.

Last oral intake (food or drink) — Date/Time:

Consent for Treatment and Authorization

I, the undersigned patient or legal representative, authorize the licensed healthcare providers and staff to perform the procedure or treatment described below and to provide such anesthesia and other care as deemed necessary. Procedure/Service:

Risks and benefits: The nature, anticipated benefits, and material risks of the proposed treatment or procedure, including potential complications, alternatives (including no treatment), and expected recovery, have been explained to me. I understand that complications may include, but are not limited to, infection, bleeding, adverse reaction to medications, anesthesia complications, scarring, and unforeseen outcomes. I acknowledge I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.

Consent for anesthesia and emergency treatment: I consent to the administration of local, regional, or general anesthesia as required and authorize emergent resuscitative and transfusion measures if deemed necessary for my safety. I understand that transfusion entails risks and consent is only for those measures required during this procedure.

Specimens, photography, and records: I authorize collection of tissue or other specimens during the procedure for diagnostic purposes and understand that photographs or video may be taken for medical records, education, or quality assurance, unless I have expressly refused such photography below.

I do NOT authorize clinical photography or video for non-clinical use (e.g., marketing).

Right to withdraw: I understand that I may withdraw this consent at any time prior to administration of anesthesia or initiation of the procedure, except to the extent that action has already been taken in reliance on this consent.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the healthcare facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the release of my medical information as necessary for treatment, payment, and healthcare operations.

I authorize the facility to disclose protected health information to the following persons (name and relationship). If none, leave blank.

Authorization Period and Limitations

This authorization is valid for the provision of care relating to the procedure described above and expires on: . If no date is provided, this authorization will be valid for one year from the date of signature unless earlier revoked in writing.

Patient Certification

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand the foregoing and consent to the treatment, tests, procedures, and disclosures described above. I have had the opportunity to discuss alternatives and risks with a member of the healthcare team and understand the potential outcomes and complications.

If signed by a legal representative, state your authority:

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