Healthcare Surgery Consent Form

Healthcare Surgery Consent Form

Patient Name:    Date of Birth:    Medical Record / ID #:

Patient Information

Insurance Information

Medical History

Procedure and Provider Information

Surgeon:    Facility:

Date of Procedure (scheduled):    Estimated Duration:

Risks, Benefits, and Alternatives

I authorize the performance of the procedure described above and any additional procedures that in the professional judgment of the surgeon are necessary or advisable. The following is a non‑exhaustive list of risks and complications associated with this surgery, anesthesia, and related care: infection, bleeding, blood clots, damage to surrounding organs or nerves, prolonged pain, poor wound healing, allergic reaction, need for further surgery, impairment of function, scarring, anesthesia complications including respiratory or cardiac events, permanent disability, and death. Unanticipated findings may require modification of the planned procedure.

Benefits: The intended benefits include diagnosis, relief of symptoms, restoration of function, prevention of disease progression, or other outcomes as discussed. Alternative treatment options, including no surgery, medical management, or alternative procedures, have been explained and discussed with me.

Anesthesia and Blood Products

Type(s) of anesthesia to be used (select all that apply):
General anesthesia    Regional / Spinal / Epidural    Local with sedation

Blood Products: I consent to the administration of blood and blood products if, in the judgment of the treating clinician, such administration is necessary for my care and safety.    I consent    I decline blood products

I authorize specimens removed during the procedure to be sent for pathological examination and agree to photographic or radiographic documentation for medical record purposes unless I explicitly decline below.    I consent    I decline

Patient Rights, Withdrawal, and Capacity

I understand that I have the right to ask questions about the procedure, its risks and benefits, and available alternatives. I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I understand that I may withdraw my consent at any time prior to the procedure without affecting my right to future care.

By signing this form I certify that I am the patient named above or that I have legal authority to sign on behalf of the patient, that I am authorized to consent to the procedure and associated care, and that I understand the information provided. If signed by a legal guardian or agent, my relationship to the patient and authority to consent are described below.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided the facility's notice of privacy practices and that I understand how my health information related to this procedure may be used and disclosed for treatment, payment, and healthcare operations. I understand I may request restrictions in writing.

I acknowledge receipt of the privacy practices notice.

Authorization and Expiration

This authorization for the procedure and ancillary care shall remain in effect until the procedure is completed and immediate postoperative care has been provided unless an earlier expiration date is specified: Expiration Date:

I certify that the foregoing statements are true to the best of my knowledge and that I have disclosed all medical information known to me that may affect the proposed procedure and anesthesia.

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