Healthcare Revision Surgery Form

HEALTHCARE REVISION SURGERY FORM

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Relationship:    Phone:

Insurance & Billing

Policy/ID Number:    Group Number:

Surgical Details

Original Procedure Performed:    Original Procedure Date:

Anticipated Procedure Date:    Proposed Anesthesia: General Regional/Spinal Local Sedation

Medical History & Current Status

Diabetes    Hypertension    Heart disease    Bleeding disorder    Lung disease    Other (specify below)

Risks, Benefits, Alternatives & Additional Consent

The surgeon has explained the diagnosis, the nature and purpose of the proposed revision procedure, the expected benefits, and the material risks, which can include but are not limited to: infection, bleeding, hematoma, wound healing problems, pain, scarring, numbness or sensory changes, damage to adjacent structures, need for revision or additional surgery, anesthesia-related complications including respiratory or cardiac events, thromboembolic events (blood clots), implant failure or rejection, and rarely permanent disability or death.

Alternatives to the proposed revision have been discussed and may include conservative management, medication, physical therapy, or no intervention. I understand that no outcome is guaranteed and that unexpected findings during surgery may require additional procedures to obtain a safe and medically appropriate result.

Authorization for additional procedures if necessary: I authorize the surgeon and surgical team to perform reasonable additional procedures in the event unanticipated conditions are discovered that, in their professional judgment, are necessary for my safety or to achieve the intended result.

I consent to the implantation or removal of prosthetic devices or hardware as deemed necessary by the surgeon. I understand that implants may remain in my body unless removed for clinical reasons and that they may trigger future imaging or diagnostic considerations.

I consent to receive blood products if, in the judgment of the treating physicians, transfusion is necessary to save life or prevent serious harm. I consent to transfusion I refuse transfusion (elective refusal may increase risk)

I consent to clinical photography and videography for medical records, treatment planning, and quality assurance. Such images will be maintained as part of my medical record. Photographs for teaching or publication will be de-identified unless a separate written authorization is obtained. I consent to photography/videography I do not consent

HIPAA Authorization & Release of Records

I authorize the release and disclosure of my medical information, including records and images, necessary for the purposes of treatment, payment, and healthcare operations to providers, insurers, and other entities involved in my care. I acknowledge receipt of the facility's privacy practices and understand my rights regarding my protected health information.

This authorization to perform the revision procedure and associated consents will remain in effect for the specified date or until revoked in writing prior to the procedure. Expiration Date:

Patient Certification & Acknowledgment

I certify that I have read and understand the information in this form, that the nature and purpose of the proposed revision procedure, its risks and benefits, the alternatives, and the likely outcome have been explained to me in terms I understand, and that my questions have been answered. I acknowledge that I have the right to withdraw my consent at any time prior to the procedure, and that withdrawal of consent after the start of surgery or other irreversible actions may not be possible.

I understand and agree that medical care and surgery involve inherent risks, and I release the surgeon, assistants, anesthesiologists, facility, and staff from liability for outcomes resulting from the risks described above, except in cases of willful misconduct or gross negligence as defined by applicable law.

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