Healthcare Surgery Forms

SURGICAL CONSENT AND AUTHORIZATION

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance & Billing

Medical History

Procedure Details & Authorization

Surgeon Name:    Facility:

Anticipated Date of Procedure:

I authorize the above-named surgeon, assistants and other healthcare providers to perform the procedure described above and to perform any additional procedures that, in the judgment of the surgeon, are necessary for the patient's safety or the successful outcome of the operation. I understand that the practice of medicine and surgery is not an exact science and that no guarantees have been made to me concerning the results of surgery.

Risks, Benefits, and Alternatives

The risks, potential complications, benefits, and reasonable alternatives to the proposed procedure have been explained to me by a physician or authorized representative. I acknowledge that I have had an opportunity to ask questions and that my questions have been answered to my satisfaction. I understand that risks may include but are not limited to:

• Bleeding or hematoma
• Infection
• Damage to adjacent organs, nerves, or structures
• Anesthetic complications, including allergic reaction
• Need for additional surgery
• Blood clots, pulmonary embolus, or stroke
• Pain, scarring, or functional loss

I understand the alternatives to the proposed procedure, including non-operative care and the risks and benefits of those alternatives. I accept the risks and consent to the procedure.

Anesthesia & Blood Products

Anesthesia to be administered: General Regional/Spinal Local/Monitored Anesthesia Care

Blood and blood products: I authorize the administration of blood and blood products if deemed medically necessary. I consent I refuse

Photography/Video: I consent to clinical photography or video recording for documentation, educational or quality assurance purposes. I understand that such images are part of my medical record. I consent I do not consent

HIPAA Authorization & Release of Information

I authorize the release of my protected health information related to the procedure described above to the following person(s) or organization(s) as necessary for treatment, payment, or healthcare operations:

This authorization expires on:

I understand that refusal to sign this authorization will not affect my ability to obtain treatment, but may affect payment or participation in certain services. I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Patient Acknowledgments

I acknowledge that I have provided a complete and accurate medical history to the best of my knowledge and that I have informed my healthcare providers of all medications, supplements and allergies. I understand my responsibilities for pre-operative instructions and that failure to follow instructions may result in cancellation or increased risk.

I understand I have the right to refuse the procedure or withdraw consent at any time prior to the administration of anesthesia or the start of the procedure.

I acknowledge receipt of the facility's written privacy practices. I acknowledge

Additional Instructions / Notes

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