Healthcare Surgery Packet

Healthcare Surgery Packet

Patient Information

Patient Name:

Date of Birth:   Medical Record / Hospital ID:

Male   Female   Other   Prefer not to say

Insurance / Billing

Medical History

Bleeding disorder or use of blood thinners: Yes   No

Tobacco use within last year: Yes   No

Procedure & Anesthesia

Surgeon:

Proposed Procedure / Treatment:

Surgical Site (if applicable):

General anesthesia   Regional / Spinal / Epidural   Local anesthesia with sedation   Monitored anesthesia care (MAC)

Informed Consent — Risks, Benefits, Alternatives

I, the undersigned, acknowledge that the proposed procedure, associated anesthesia, and related care have been explained to me by the treating clinician including the nature of the procedure, expected benefits, significant risks, and reasonable alternatives. I understand that risks may include, but are not limited to, infection, bleeding, scarring, damage to adjacent structures, anesthesia complications, need for further procedures, and death. I further understand that no guarantee has been made regarding the outcome.

Alternatives to the proposed procedure, including non-operative management and other surgical options, have been discussed. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I consent to the administration of local, regional, or general anesthesia as deemed necessary by the anesthesiologist or provider and consent to any other routine procedures (such as placement of IV lines or catheters) required for safe administration of anesthesia.

I acknowledge that blood transfusion may be necessary during or after the procedure. I consent to receive blood and blood products if medically indicated: Yes   No

Photography / Recording

I authorize the taking of clinical photographs, video, or audio recordings for medical documentation, diagnostic, or treatment purposes. I understand that identifying information will be protected in accordance with privacy laws unless specifically otherwise authorized.

Consent to clinical photography: Yes   No

HIPAA Authorization & Release of Information

I authorize the disclosure of my protected health information to the entities and persons involved in my care, including referring physicians, consultants, insurers, and other health care providers for the purpose of treatment, payment, and health care operations. I understand that this authorization includes release of records related to diagnosis, treatment, and billing.

Financial Responsibility & Acknowledgments

I accept financial responsibility for charges related to the procedure, anesthesia, and post-operative care to the extent not covered by insurance. I authorize release of medical records to my insurance carrier for adjudication of claims and assign benefits to the treating facility and providers where applicable.

I understand I may withdraw consent at any time prior to administration of anesthesia or the start of the surgical procedure, except in emergencies where withdrawal would compromise care.

Preoperative Acknowledgements

I certify that I have provided a complete and accurate medical history, including medications and allergies, and that I have followed fasting and medication instructions as directed. I have been informed when to stop eating and drinking and which medications to take or hold before surgery.

I acknowledge that I received and understand the preoperative instructions.

Patient Certification

By signing below I certify that I have read (or have had read to me) this document, that the procedure, risks, benefits, and alternatives have been explained to me, and that all of my questions have been answered. I understand that unforeseen conditions may arise during the procedure that necessitate procedures not specifically described here and I authorize the surgeon and medical staff to perform such procedures as are, in their professional judgment, necessary and desirable.

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