Vascular Surgery Patient Care Agreement and Consent

Patient Information

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

Agreement Terms

1. Scope of Services

I understand that [Practice Name] will provide vascular surgery services, including but not limited to:

• Diagnostic evaluations
• Surgical procedures
• Post-operative care
• Follow-up visits

2. Patient Responsibilities

I agree to:

• Provide accurate medical history and information
• Follow pre-operative and post-operative instructions
• Attend all scheduled appointments
• Notify the practice of any changes in condition
• Maintain current contact information
• Adhere to prescribed medication regimens

3. Financial Responsibilities

• I understand I am responsible for applicable co-pays and deductibles
• I will provide current insurance information
• I agree to pay for non-covered services

4. Surgical Consent

I acknowledge that:

• All surgical procedures carry inherent risks
• Separate surgical consent forms will be required
• Alternative treatment options will be discussed

5. Emergency Protocol

• I understand the protocol for after-hours emergencies
• I will call 911 for life-threatening emergencies
• I have received emergency contact information

6. Privacy and Communication

I consent to:

• The practice's privacy policies
• Electronic communication when appropriate
• Release of medical information to authorized parties

Signatures

Patient/Guardian: _________________ Date: __________

Provider: ________________________ Date: __________

Witness: _________________________ Date: __________