Healthcare SafeT Document

Healthcare SafeT Document

Patient Information

Patient Name:

Date of Birth:   Gender:

Insurance Information

Medical History and Safety Screening

Do you have any implanted medical device (pacemaker, infusion pump, etc.)?

Safety Screening — Check all that apply

Fever or chills    Cough    Shortness of breath    Sore throat

New loss of taste or smell    Known recent exposure to communicable illness    Recent international travel within 14 days

If any screening boxes are checked, describe symptoms, onset date, or exposure details:

Procedure / Service and Consent

Procedure / Service to be provided:

I hereby authorize the health care professionals and supporting staff of the facility to perform the procedure(s) or provide the services described above and to administer such examinations, tests and treatments as are reasonably necessary in connection with the provision of such services. I understand that medical care involves risks and potential complications, including, but not limited to, infection, bleeding, allergic reaction, and unforeseen adverse outcomes. I acknowledge that no guarantees have been made to me as to the results of the procedure or treatment.

I understand that I have the right to be informed of the nature and purpose of the proposed procedure(s), the expected benefits, material risks, common alternatives (including the option of no treatment), and the likely consequences of refusing or withdrawing consent. I have had the opportunity to ask questions and they have been answered to my satisfaction.

I consent to the administration of routine tests, including but not limited to blood tests and swab tests necessary for safety screening and infection control. I consent to the use of my medical information as described in the Privacy and Authorization clause below for purposes of treatment, payment, and health care operations.

Privacy, Release and Authorization

Authorization to Use and Disclose Protected Health Information: I authorize the disclosure of my protected health information, including records of diagnoses, treatments, test results, and other relevant health information, to health care personnel, billing agents, and other entities as necessary for treatment, payment, appointment scheduling, and health care operations. This authorization includes limited disclosure for the purpose of contacting me regarding appointment reminders, billing, and care coordination.

I understand that this authorization is voluntary. I may revoke this authorization at any time by providing written notice to the facility, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures made prior to the revocation.

By initialing below I acknowledge I have read and understand the Privacy, Release and Authorization statements and consent to the uses and disclosures described.

Initials:

Acknowledgment and Certifications

I certify that the information I have provided on this Healthcare SafeT Document is true and correct to the best of my knowledge. I understand that withholding information or providing false information may jeopardize my care and may be considered a breach of facility policy. I agree to notify the facility promptly of any changes in my health status or contact information prior to any scheduled procedure.

I acknowledge that I have been given the opportunity to ask questions about safety screening, infection control, and the procedure, and that those questions have been answered to my satisfaction.

Acknowledgments (select applicable)

I acknowledge receipt of the facility's privacy practices and the opportunity to ask questions about them.
I understand the material risks and alternatives associated with the proposed services.
I authorize emergency treatment if necessary in the event of an adverse reaction or complication.
I consent to clinical photography for medical records and treatment documentation only (no marketing) unless otherwise specified in writing.

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