Healthcare Surgery Attestation

HEALTHCARE SURGERY ATTESTATION

Patient Identification

Patient Name:   Medical Record/ID:

Date of Birth:   Gender: Male Female Other

Contact & Emergency Information

Insurance

Planned Procedure

Procedure / Service:   Surgeon / Responsible Provider:

Scheduled Date:   Facility:

Medical History

Preoperative Instructions & Acknowledgements

I acknowledge that I have been instructed on preoperative requirements (including NPO status, medication instructions, and arrival time). I confirm that I understand these requirements and will follow them:

I will adhere to NPO (nothing by mouth) instructions as directed.

I have received medication instructions for the perioperative period.

Attestation of Informed Consent Elements

The following attestation statements indicate that I have been informed and understand the nature of the planned procedure, reasonably foreseeable risks, benefits, and alternatives, and that I have had an opportunity to ask questions:

Surgeon/provider has explained the intended procedure, expected benefits, material risks, and reasonable alternatives.

Alternatives (including no treatment) were discussed and I understand them.

I had the opportunity to ask questions and they were answered to my satisfaction.

Consents (select all that apply)

I consent to the planned procedure as described above, including routine operative care and necessary variations as judged appropriate by the surgeon.

I consent to administration of anesthesia as recommended by the anesthesiology team and understand the associated risks.

I consent to blood transfusion if medically necessary. (If you refuse, initial and provide alternative instructions below.)

Privacy & Authorization

I acknowledge receipt of the facility's privacy practices and understand how my health information will be used for my care.

By signing below I authorize the release of medical information to insurers and other health care providers as necessary for treatment, payment, and health care operations, as permitted by law.

Patient Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that I may withdraw my consent at any time prior to the procedure by notifying the responsible provider, except to the extent that action has already been taken in reliance on this consent. I understand that unforeseen conditions may require additional or different procedures than those listed, and I authorize the surgical team to perform such additional procedures if they are necessary for my safety.

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