Colorectal Surgery Patient Care Agreement and Informed Consent

This agreement is made between _________________________ ("Patient") and _________________________ ("Surgeon/Practice").

1. SCOPE OF SERVICES

Services Provided

• Comprehensive colorectal evaluation
• Pre-operative planning and optimization
• Surgical intervention as deemed necessary
• Post-operative care and follow-up
• Emergency care coordination when applicable

Procedures Covered

This agreement may include, but is not limited to:

• Colonoscopy and related procedures
• Colorectal cancer surgery
• Inflammatory bowel disease surgery
• Anal/rectal procedures
• Minimally invasive surgical approaches

2. PATIENT RESPONSIBILITIES

Pre-operative Period

• Provide accurate medical history
• Follow pre-operative instructions precisely
• Complete all required testing
• Inform surgeon of medication changes

Post-operative Period

• Attend all scheduled follow-up appointments
• Follow wound care instructions
• Report complications promptly
• Adhere to dietary restrictions

3. PRACTICE RESPONSIBILITIES

• Provide evidence-based surgical care
• Maintain patient confidentiality
• Coordinate with other healthcare providers
• Provide emergency contact information
• Document all care appropriately

4. FINANCIAL RESPONSIBILITIES

• Insurance verification and coordination
• Discussion of anticipated costs
• Payment arrangements
• Billing procedures

5. CONSENT AND ACKNOWLEDGMENT

I understand and agree to the terms outlined above:

Patient Signature: _______________ Date: _______________

Surgeon Signature: ______________ Date: _______________

Witness Signature: ______________ Date: _______________