General Surgery Patient-Provider Agreement and Consent

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

1. Scope of Services

Medical Services

• Preoperative consultation and evaluation
• Surgical procedure(s) as discussed and agreed upon
• Post-operative care for [specify duration]
• Follow-up visits as medically indicated

Financial Responsibilities

• Patient agrees to pay all applicable fees
• Insurance coverage verification responsibility
• Payment for non-covered services

2. Patient Responsibilities

Medical Information

• Provide accurate medical history
• Disclose all medications and supplements
• Report any changes in health status
• Inform about previous surgical procedures

Compliance Requirements

• Follow pre-operative instructions
• Attend scheduled appointments
• Adhere to post-operative care guidelines
• Maintain follow-up schedule

3. Surgeon/Practice Commitments

• Provide care meeting medical standards
• Maintain patient confidentiality
• Provide emergency contact information
• Communicate surgical risks and benefits

4. Informed Consent

• Separate surgical consent to be signed
• Right to refuse treatment
• Documentation of surgical risks
• Alternative treatment options discussed

5. Privacy Practices

• Compliance with HIPAA regulations
• Medical information use and disclosure
• Patient rights regarding medical records

Signatures

Patient: _________________ Date: _________

Surgeon: _________________ Date: _________

Witness: _________________ Date: _________