Authorization for Vascular Surgery Treatment and Procedures

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________ Date: ____________________

Consent for Treatment

I, the undersigned patient (or authorized representative), consent to the medical care and treatment procedures that may be performed during this visit and future visits at [PRACTICE NAME]. These procedures may include, but are not limited to:

• Diagnostic imaging studies
• Laboratory tests
• Vascular ultrasound examinations
• Endovascular procedures
• Surgical interventions
• Administration of medications and/or biological products

Financial Agreement

I understand that I am financially responsible for all charges, whether covered by my insurance or not. I authorize the release of any medical information necessary to process insurance claims.

Assignment of Benefits

I hereby assign all medical benefits to which I am entitled to [PRACTICE NAME]. This assignment will remain in effect until revoked by me in writing.

Emergency Contact Authorization

I authorize [PRACTICE NAME] to contact the following person in case of emergency:

Name: _________________________ Relationship: _____________ Phone: ________________________

Acknowledgment

I have read and understand this authorization. I have had the opportunity to ask questions, and my questions have been answered satisfactorily.

Patient/Guardian Signature Date

Witness Signature Date

Practice Information

[PRACTICE NAME] [ADDRESS] [PHONE] [FAX]

Form ID: VAS-AUTH-001 Revision Date: [DATE]