Healthcare Surgery Check In Form

HEALTHCARE SURGERY CHECK IN FORM

Please complete this form upon arrival for your scheduled surgical procedure. The information you provide will be used to verify identity, surgical and anesthetic plans, allergies, medications, and consent status. By signing at the end of this form you confirm that the information is true and complete to the best of your knowledge, you acknowledge the pre-operative instructions have been followed unless indicated otherwise, and you authorize the surgical and perioperative team to proceed as clinically indicated.

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Procedure & Scheduling

Surgeon:

Procedure Site: Left Right Bilateral Other

Scheduled Date:    Arrival Time:    Facility:

Medical History & Pre-Op Checklist

Have you taken your routine morning medications today? Yes No If yes, list timing and medications:

NPO (nothing by mouth) since:    If not NPO, explain:

Do you have a history of bleeding disorder or are you taking anticoagulants? Yes No

Female patients of childbearing potential: Last menstrual period:    Pregnancy test performed: Positive Negative Not applicable

Anesthesia & Special Authorizations

Planned Anesthesia Type: Local Regional General MAC (Monitored Anesthesia Care)

Do you consent to administration of blood products if medically required during your care? Yes No

Do you have an advance directive or Do-Not-Resuscitate order relevant to this admission? Yes No If yes, summary or location:

HIPAA & Privacy Acknowledgment

I acknowledge that I have received and have had the opportunity to review the facility's Notice of Privacy Practices. I authorize the release of my protected health information for treatment, payment, and health care operations as necessary for my surgical care. This authorization includes the release of reports and images to consultants and payors as required for my care.

I acknowledge and authorize as stated above.

This authorization expires on:

Patient Certification & Consent Confirmation

I certify that I am the patient or the legally authorized representative of the patient and that I have provided accurate and complete medical history information. I understand the nature of the planned procedure and that the surgeon and anesthesiologist will discuss risks, benefits, and alternatives prior to the procedure. I understand that I may withdraw consent at any time prior to administration of sedation or anesthesia. I authorize the surgical team to perform the procedure described above and to provide such care as is necessary in the event of an unexpected condition.

I consent to the use of photographs or recordings for clinical documentation or educational purposes, with personal identifiers removed unless I give additional written permission. Yes No

I understand that if any information changes prior to the surgery (medication use, pregnancy status, recent illness), I must notify the pre-operative nursing staff immediately.

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