Patient Name*
Date* ASC#
Consent to Medical Care: I request admission to the Philadelphia Surgi-Center and authorize the facility, staff and physicians to provide care. I request and consent to medical care and diagnostic procedures that my attending physician(s) or his/her designees, determine are necessary. I acknowledge that the medical care I receive while in the Philadelphia Surgi-Center is not responsible for acts of omission of my attending physician(s). I authorize the Philadelphia Surgi-Center to retain or dispose of any specimen or tissue taken from the above named patient.
Teaching Programs: I understand that this Philadelphia Surgi-Center is a facility that promotes education opportunities, and therefore, I understand that I may be seen and examined by supervised participants as a part of the educational program. I agree to participate in these programs, but reserve the right to limit my participation at any time.
Disclosure of Information: The undersigned agrees that all records concerning this patient's admission shall remain the property of the facility. The undersigned understands that medical records and billing information generator or maintained by the facility are accessible to facility personnel and medical staff. Facility personnel and medical staff may use and disclose medical information for treatment, payment and healthcare operations and to any other physician, healthcare personnel or provider that is or may be involved in the continuum of care for this admission. The facility is authorized to disclose all or part of the patient's medical record to any insurance company, third party payor, workers compensation carrier, self-insured employer group or other entity (or their authorized representatives) which are necessary for payment of patient's account. Law requires that the facility advise the undersigned that THE INFORMATION RELEASED MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT NOT BE LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILIS, HONORRHEA AND THE HUMAN IMMUNODEFICIENCY VIRUS, ALSO KNOWN AS AQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS). The facility is authorized to disclose all or any portion of the patient's medical record as set forth in its Notice of Privacy Practices, unless the patient objects in writing. By signing this form, you are authorizing such disclosures.
Special Consent for HIV/Hepatitis Testing: The undersigned specifically consents to the testing of the patient's blood for human immunodeficiency virus (also known as AIDS) and/or Hepatitis if determined by the patient's attending physician to be necessary (i) for determining the appropriate treatment and/or treatment procedures for the patient or (ii) for protection of the attending physician and/or any employee or agent of the facility exposed to the bodily fluids of the patient in a manner which could transmit such disease. The undersigned has been informed about the nature of the bloog test, its expected benefit, and has been given the opportunity to ask questions about the blood test
I (we) authorize Philadelphia Surgi-Center and/or my physician to photograph/video or permit other persons to photograph/video for such purposes as may be deemed necessary. DoDo Not
Acknowledgement and Consent for Anesthesia: I acknowledge that I have read and understand this form or it has been read to me) including all the medical terms about which I have asked if unsure, than all my questions about anesthesia have been answered by the anesthesiologist in a satisfactory manner, that I have honestly answered all health-related questions asked of me, and that I have been explained to my satisfaction all the risks & complications associated with anesthesia. I understand them and accept the risks. I likewise understand and accept the specific anesthesia plan selected for me as indicated above. I also acknowledge and understand that while I am under anesthesia, conditions may arise that requre the anesthesiologist to perform additional procedures that werenot planned when I signed this Anesthesia Consent form. This includes changing from one type of anesthetic to another or placement of additional invasive monitoring devices as medically indicated. Therefore, I authorize my anesthesiologist, other personnel who may be otherwise involved in administering my anesthesia, and all medical personnel under the supervision or control of my anesthesiologist to perform such additional procedures, as the anesthesiologist deems medically necessary.
I voluntarily consent to the administration of anesthesia and to all procedures deemed medically necessary or appropriate by a member of Delaware Valley Anesthesia. This consent shall be valid until revoked by me in writing.
E-Signature of Patient*
Witness* Relationship to patient
Signature of Authorized Representative*
Physician Obtaining Signature* Time
