Healthcare Surgeons Form

HEALTHCARE SURGEONS FORM

Patient Information

Date of Birth:    Gender: Male   Female   Other

Phone:    Email:

Relationship:    Phone:

Insurance & Billing

Policy Number:    Group Number:

Surgical Procedure Details

Scheduled Procedure Date:    Estimated Duration:

Medical History & Current Status

Pre-Operative Checklist

NPO (no solid food) since:

Patient has been advised regarding medication instructions:

Pregnancy status (if applicable): Yes   No

Informed Consent for Surgery and Related Treatment

I, the undersigned, authorize the attending surgeon and such assistants as may be selected to perform the procedure described above, and to administer such anesthetic and perform such additional procedures as are advisable and necessary in the surgeon's professional judgment, including treatment of conditions not anticipated at the time of the operation. I understand that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees have been made regarding the results of the proposed procedure.

I have read and had explained to me the common and rare but serious risks associated with this procedure, which include but are not limited to: infection, bleeding, blood clots, anesthetic complications, nerve injury, organ or tissue injury, need for additional surgery, scarring, persistent pain or loss of function, and death. I understand that complications can occur despite appropriate care.

Acknowledgement of review of risks:

Alternatives, including conservative (non-surgical) management, have been discussed with me, and I understand the risks and benefits of these alternatives. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Acknowledgement of alternatives:

Anesthesia, Blood and Tissue Authorization

I consent to the administration of anesthesia (local, regional, or general) as deemed necessary by the anesthesiologist or surgeon. I consent to blood transfusions and blood products if, in the judgment of the attending physicians, they are necessary for my care: Yes   Refuse

I consent to the removal and disposal or pathological examination of tissue as necessary. I authorize the use of photographs or recordings for medical records, education, or quality assurance unless I check here to decline: Decline

HIPAA and Privacy Acknowledgement

I acknowledge that I have received the facility's privacy practices and that I understand how my protected health information may be used and disclosed for treatment, payment, and healthcare operations. I authorize release of necessary medical information to insurance carriers and other entities as required for billing and treatment continuity.

Acknowledgement of HIPAA/privacy notice:

Authorization, Expiration and Withdrawal

This authorization for surgery and related treatment will remain in effect until the completion of the procedure unless otherwise revoked in writing. Authorization expiration date:

I understand that I may withdraw this consent at any time prior to the procedure by providing written notice to the facility; however, withdrawal may not be effective if the surgery has already begun or if the withdrawal jeopardizes my care.

Additional Authorizations

Relationship:    Phone:

Certifications and Acknowledgements

By signing below I certify that I have read and fully understand the information contained in this form, that the information I have provided is accurate to the best of my knowledge, and that I have had the opportunity to ask questions about the diagnosis, the nature and purpose of the procedure, reasonable alternatives, and the risks and benefits. I consent to the performance of the procedure and associated care as described above.

Sign Now