Healthcare Surgeon Form

HEALTHCARE SURGEON FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Preoperative Medical History

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

Procedure Details

Proposed Procedure / Operation:

Indication / Diagnosis:

Risks, Benefits, and Alternatives

The surgeon has explained the nature and purpose of the proposed procedure, reasonable alternatives (including no surgery), and the reasonably foreseeable risks, which may include, but are not limited to:

• Infection, bleeding, blood clots (deep vein thrombosis / pulmonary embolus), scarring.
• Damage to adjacent organs, nerves, or blood vessels with possible functional impairment.
• Anesthesia-related complications, including allergic reaction and respiratory or cardiac events.
• Need for additional procedures, conversion to open operation, or incomplete relief of symptoms.
• Possible permanent disability or death in rare circumstances.

I acknowledge that the list above is not exhaustive and that individual risks specific to my condition were discussed by the surgeon.

I understand the expected benefits:

Anesthesia and Blood Products

Type of anesthesia planned:

Consent for blood transfusion if medically necessary:   I consent   I refuse

Implants, Devices, and Specimens

Implant or prosthesis to be used (if applicable):

I authorize disposition of surgical specimens for pathological examination as indicated by the surgeon: Yes No

Photography / Recording

I authorize photography, videography, or other recordings for medical records, treatment documentation, and education. I understand identifying features will be removed when used for teaching unless I provide separate written authorization.

Consent to photography:   Yes   No

HIPAA / Release of Information

I authorize release of my protected health information to the individuals and entities involved in my care for purposes of treatment, payment, and healthcare operations. I understand my information may be disclosed as necessary for my treatment and insurance claims.

I have received or been offered the facility's Privacy Notice:   Yes   Declined

Authorization and Consent

By signing below I authorize the surgeon, assistants, anesthesia provider, and other personnel to perform the indicated procedure and any additional procedures that are necessary or advisable in the professional judgment of the surgeon during the operation. I understand that no guarantee or assurance has been made regarding the results. I accept the risks described above and consent to both routine and unusual care as medically necessary.

I understand that I may withdraw this consent at any time prior to the procedure by notifying the surgeon or facility. Withdrawal of consent will be documented in my medical record but will not affect actions already taken based on this consent.

Patient Affirmations

I acknowledge the surgeon has answered my questions and explained the procedure, alternatives, and risks in language I understand.

I understand I must follow preoperative instructions provided by the surgeon and facility. If I suspect I am pregnant or am of childbearing potential, I will inform the surgeon and undergo appropriate testing as required.

Additional Authorizations

Advance directives present:   Yes   No

Acknowledgment of Understanding

By checking the box below I affirm that I have read and understand this form or that it was read to me and my questions have been answered.

I understand and consent to the procedure and associated care.

Sign Now