Surgical Facility Rules Acknowledgment Form

Surgical Facility Rules Acknowledgment Form
Please review and acknowledge the facility rules before your surgical procedure.
Full Name
First NameLast Name
Date
MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please read the following surgical facility rules carefully. By acknowledging below, you confirm that you have read, understood, and agree to comply with all facility rules, including but not limited to:

- Arriving at least 30 minutes prior to your scheduled procedure time.
- Following all pre-operative and post-operative instructions provided by the medical staff.
- Notifying staff of any changes in your health condition prior to surgery.
- Complying with all infection control and safety protocols within the facility.
- Respecting the privacy and safety of other patients and staff.

If you have any questions about these rules, please contact the facility prior to your procedure.
Should be Empty: