Healthcare Regenerative Medicine Packet

HEALTHCARE REGENERATIVE MEDICINE PACKET

Patient Information

Patient Name:

Male    Female    Other    Prefer not to say

Emergency Contact & Primary Care

Insurance Information

Medical History

Are you pregnant, attempting to become pregnant, or breastfeeding?    Yes    No

Do you take anticoagulant or antiplatelet medications (e.g., warfarin, aspirin, clopidogrel) or have a bleeding disorder?    Yes    No

Regenerative Procedure Information & Consent

Procedure(s) Proposed:

Platelet-Rich Plasma (PRP)    Autologous Stem Cell / Bone Marrow Aspirate    Adipose-Derived Cell Therapy    Allogeneic/Off-the-Shelf Biologics    Other:

Description of procedure, steps, and expected course:

Risks, potential complications, and limitations (including but not limited to infection, bleeding, pain, no improvement, allergic reaction, need for further treatment). I understand regenerative therapies may be considered investigational or off-label and outcomes are not guaranteed.

I acknowledge that the risks, benefits, alternatives, and expected outcomes have been explained to me and that I have had the opportunity to ask questions and receive answers to my satisfaction.    I acknowledge and consent to proceed.

Pre-Procedure Instructions

Please confirm you have been advised of the following and will comply:

Avoid aspirin and NSAIDs for 7 days prior unless directed otherwise by prescribing physician.
Discuss stopping anticoagulants with prescribing clinician prior to procedure if applicable.
Avoid alcohol for 24 hours before procedure.
Notify clinic if any active infection or fever is present on day of procedure.

Authorization for Use and Disclosure of Medical Information (HIPAA)

I authorize the release and use of my medical information, including procedure details, for treatment, payment, and healthcare operations as required. I understand that my information may be used in de-identified form for research and quality improvement activities and that I will not be identified by name in such reports.

I authorize the clinic and staff to communicate protected health information to the following individual(s):

Authorization expiration (if any):    No expiration specified (until revoked)

Photography / Video / Data Use

I consent to clinical photography, video recording, and use of images and de-identified data for medical record documentation, education, and internal quality improvement. I understand identifiable images will not be used for marketing without separate written consent.    I consent    I decline

Financial Responsibility

I understand that regenerative medicine procedures are frequently considered elective and may not be covered by insurance. I accept financial responsibility for all charges related to my care that are not paid by my insurer. I authorize the clinic to bill my insurer and to disclose necessary information for claim processing.    I agree to financial responsibility.

Cancellation and refund policy: Fees and deposits may be non-refundable per clinic policy. Failure to follow pre-procedure instructions may result in rescheduling and additional fees.    I acknowledge and accept the cancellation policy.

Patient Certification and Consent

By signing below I certify that I have read and understand this packet in its entirety, that the information I have provided is true and complete to the best of my knowledge, that I have had an opportunity to ask questions and that all my questions have been answered to my satisfaction. I consent to the performance of the proposed regenerative medicine procedures and related care. I understand that I may withdraw consent at any time prior to the procedure.

I release and hold harmless the clinic, physicians, and staff from liability for unforeseen complications except in the case of gross negligence or willful misconduct. I acknowledge no guarantees have been made regarding outcomes.

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