36C10A19R0063-005.pdf

# of Forms

Specialty Category Document Name

1 Allergy Consent Form Allergy ‐ Patch Test 2 Allergy Consent Form Allergy Skin Testing ‐ Intradermal Skin Test 3 Allergy Consent Form Allergy Skin Testing ‐ Prick and Scratch Test 4 Allergy Consent Form Bronchoprovocation Challenge Testing 5 Allergy Consent Form Exercise Challenge Test 6 Allergy Consent Form Immunotherapy 7 Allergy Consent Form Local Anesthesia 8 Allergy Consent Form Medication Desensitization 9 Allergy Consent Form Mepolizumab 10 Allergy Consent Form Nose/Larynx ‐ Rhinolaryngoscopy 11 Allergy Consent Form Omalizumab (Xolair) Injection 12 Allergy Consent Form Oral Food Challenge Test 13 Allergy Consent Form Skin ‐ Skin Lesion Biopsy 14 Anesthesia Consent Form Anesthesia General 15 Anesthesia Consent Form Deep Sedation 16 Anesthesia Consent Form Endotracheal Intubation 17 Anesthesia Consent Form Epidural/Spinal Anesthesia 18 Anesthesia Consent Form Epidural/Spinal Anesthesia (Labor and Delivery, including Cesarean Section) 19 Anesthesia Consent Form Intravenous Regional Anesthesia 20 Anesthesia Consent Form Ligament ‐ Iliolumbar Ligament Injection 21 Anesthesia Consent Form Minimal Sedation 22 Anesthesia Consent Form Moderate Sedation with Analgesia ‐ Stand Alone Procedure 23 Anesthesia Consent Form Monitored Anesthesia Care 24 Anesthesia Consent Form Nerve Block ‐ Transversus Abdominis Plane (TAP) Block 25 Anesthesia Consent Form Occipital Nerve Block 26 Anesthesia Consent Form Spinal ‐ Epidural Blood Patch 27 Anesthesia Consent Form Spinal Anesthesia 28 Bariatric Consent Form Gastrojejunostomy (Laparoscopic Possible Open) 29 Bariatric Consent Form Gastrojejunostomy (Open) 30 Bariatric Consent Form Gastrojejunostomy (Robotic‐Assisted Laparoscopic Possible Open) 31 Bariatric Consent Form Stomach ‐ Adjustable Gastric Band Placement 32 Bariatric Consent Form Stomach ‐ Adjustable Gastric Band Placement (Open) 33 Bariatric Consent Form Stomach ‐ Conversion of Sleeve Gastrectomy to Roux‐en‐Y Gastric Bypass with Possible Upper Endoscopy (Laparoscopic Possible Open) 34 Bariatric Consent Form Stomach ‐ Conversion of Sleeve Gastrectomy to Roux‐en‐Y Gastric Bypass with Possible Upper Endoscopy (Open) 35 Bariatric Consent Form Stomach ‐ Implantable Gastric Stimulation 36 Bariatric Consent Form Stomach ‐ Removal of Adjustable Gastric Band (Laparoscopic) 37 Bariatric Consent Form Stomach ‐ Removal of Adjustable Gastric Band (Open) 38 Bariatric Consent Form Stomach ‐ Roux‐en‐Y Gastric Bypass (Open) 39 Bariatric Consent Form Stomach ‐ Sleeve Gastrectomy (Laparoscopic) 40 Bariatric Consent Form Vagal Nerve Block Device Placement (Laparoscopic Possible Open) 41 Cardiac Surgery Consent Form Aorta ‐ Abdominal Aortic Aneurysm (AAA) Repair ‐ Open 42 Cardiac Surgery Consent Form Aorta ‐ Aortic Valve Replacement or Repair 43 Cardiac Surgery Consent Form Aorta ‐ Aortoplasty 44 Cardiac Surgery Consent Form Aorta ‐ Ascending Aortic Repair w/ CP Bypass 45 Cardiac Surgery Consent Form Aorta ‐ Descending Aortic Repair 46 Cardiac Surgery Consent Form Aorta ‐ Descending Aortic Repair w/ CP Bypass 47 Cardiac Surgery Consent Form Aorta ‐ Intra Aortic Balloon Pump Placement 48 Cardiac Surgery Consent Form Aorta ‐ Thoracic Repair (TEVAR) 49 Cardiac Surgery Consent Form Artery ‐ Angiogram (Abdomen) 50 Cardiac Surgery Consent Form Artery ‐ Angiography ‐ Above Aortic Arch 51 Cardiac Surgery Consent Form Artery ‐ Angiography ‐ Below Aortic Arch 52 Cardiac Surgery Consent Form Artery ‐ Atherectomy Coronary 53 Cardiac Surgery Consent Form Artery ‐ Lysis ‐ Coronary 54 Cardiac Surgery Consent Form Artery ‐ Stent ‐ Below Aortic Arch

55 Cardiac Surgery Consent Form Artery ‐ Thrombectomy Mechanical ‐ Coronary 56 Cardiac Surgery Consent Form Artery ‐ Thrombolytic Therapy Arterial Injection 57 Cardiac Surgery Consent Form Atrium ‐ Atrial Septal Defect Repair or Closure 58 Cardiac Surgery Consent Form Blood Transfusion 59 Cardiac Surgery Consent Form Bone ‐ Biopsy, Open 60 Cardiac Surgery Consent Form Chest ‐ Chest Tube Placement 61 Cardiac Surgery Consent Form Coronary Artery ‐ CABG with CP Bypass 62 Cardiac Surgery Consent Form Coronary Artery ‐ CABG without CP Bypass 63 Cardiac Surgery Consent Form Coronary Artery ‐ Insertion of Drug‐Eluting Stent 64 Cardiac Surgery Consent Form ECMO Tubing Insertion 65 Cardiac Surgery Consent Form Heart ‐ Aortic Valve Replacement (Open) 66 Cardiac Surgery Consent Form Heart ‐ Aortic Valve Replacement (Transapical) 67 Cardiac Surgery Consent Form Heart ‐ Aortic Valve Replacement (Transfemoral) 68 Cardiac Surgery Consent Form Heart ‐ Biopsy 69 Cardiac Surgery Consent Form Heart ‐ Cardiac Tumor Removal 70 Cardiac Surgery Consent Form Heart ‐ Cardiopulmonary Bypass 71 Cardiac Surgery Consent Form Heart ‐ CRT‐D, ICD, Pacemaker ‐ Lead Revision 72 Cardiac Surgery Consent Form Heart ‐ CRT‐D, ICD, Pacemaker ‐ Transvenous Lead Initial Insertion 73 Cardiac Surgery Consent Form Heart ‐ CRT‐D, ICD, Pacemaker‐Generator Replacement 74 Cardiac Surgery Consent Form Heart ‐ Epicardial Lead Placement 75 Cardiac Surgery Consent Form Heart ‐ Heart Transplantation (Adult) 76 Cardiac Surgery Consent Form Heart ‐ ICD Placement 77 Cardiac Surgery Consent Form Heart ‐ Intra‐Atrial Septostomy 78 Cardiac Surgery Consent Form Heart ‐ Lead Removal for CRT‐D, ICD, or Pacemaker 79 Cardiac Surgery Consent Form Heart ‐ Left Atrial Appendage Exclusion (Open) 80 Cardiac Surgery Consent Form Heart ‐ Left Atrial Appendage Exclusion (Percutaneous) 81 Cardiac Surgery Consent Form Heart ‐ Left Ventricular Aneurysm Repair 82 Cardiac Surgery Consent Form Heart ‐ Left Ventricular Assist Device Implantation 83 Cardiac Surgery Consent Form Heart ‐ MAZE 84 Cardiac Surgery Consent Form Heart ‐ Mini‐Maze Ablation Procedure 85 Cardiac Surgery Consent Form Heart ‐ Mitral Valve Replacement (Open) 86 Cardiac Surgery Consent Form Heart ‐ Pacemaker or ICD Replacement 87 Cardiac Surgery Consent Form Heart ‐ Patent Foramen Ovale Closure (Percutaneous) 88 Cardiac Surgery Consent Form Heart ‐ Percutaneous Implantation of Intracardiac Leadless Pacemaker 89 Cardiac Surgery Consent Form Heart ‐ Permanent Pacemaker Placement 90 Cardiac Surgery Consent Form Heart ‐ Permanent Pacemaker Placement (Biventricular) 91 Cardiac Surgery Consent Form Heart ‐ Re‐exploration of the Heart for Hemostasis 92 Cardiac Surgery Consent Form Heart ‐ Removal of Loop Recorder 93 Cardiac Surgery Consent Form Heart ‐ Temporary Pacemaker Placement 94 Cardiac Surgery Consent Form Heart ‐ Transmyocardial Laser Revascularization (TMLR) 95 Cardiac Surgery Consent Form Heart ‐ Tricuspid Valve Repair (Open) 96 Cardiac Surgery Consent Form Heart ‐ Tricuspid Valve Replacement (Open) 97 Cardiac Surgery Consent Form Mitral Valve ‐ Repair or Replacement 98 Cardiac Surgery Consent Form Nodes/Groin ‐ Inguinal Lymphadenectomy (Open) 99 Cardiac Surgery Consent Form Pericardium ‐ Pericardial Excision 100 Cardiac Surgery Consent Form Pericardium ‐ Pericardiotomy 101 Cardiac Surgery Consent Form Pulmonary Artery ‐ Thrombectomy or Thromboendarterectomy CP Bypass 102 Cardiac Surgery Consent Form Soft Tissue ‐ Foreign Body Removal 103 Cardiac Surgery Consent Form Sternum ‐ Re‐exploration and Re‐instrumentation 104 Cardiac Surgery Consent Form Sternum ‐ Sternal Wire Removal 105 Cardiac Surgery Consent Form Thorax ‐ Mediastinoscopy 106 Cardiac Surgery Consent Form Thorax ‐ Pleurodesis 107 Cardiac Surgery Consent Form Tricuspid Valve ‐ Repair or Replacement 108 Cardiac Surgery Consent Form Vein ‐ Central Venous Catheter Placement 109 Cardiac Surgery Consent Form Vein ‐ Central Venous Catheter Placement (VAD) 110 Cardiac Surgery Consent Form Vein ‐ Harvesting (Endoscopic Possible Open)

111 Cardiac Surgery Consent Form Vein ‐ Venogram Jugular/Carotid 112 Cardiac Surgery Consent Form Ventricle ‐ Ventricular Septal Defect Repair 113 Cardiac Surgery Consent Form Wound ‐ Debridement 114 Cardiology Consent Form Artery ‐ Implant of Pulmonary Artery Pressure Monitor 115 Cardiology Consent Form Artery ‐ PTA ‐ Above Aortic Arch 116 Cardiology Consent Form Artery ‐ PTA ‐ Below Aortic Arch 117 Cardiology Consent Form Artery ‐ Stent ‐ Above Aortic Arch (VA) 118 Cardiology Consent Form Artery ‐ Stent Graft Coronary Artery 119 Cardiology Consent Form Cardiac CT Scan with Contrast Medium 120 Cardiology Consent Form Defibrillator Threshold Testing 121 Cardiology Consent Form Device Pocket Revision 122 Cardiology Consent Form Heart ‐ Alcohol Septal Ablation 123 Cardiology Consent Form Heart ‐ Atrial Septal Defect Closure (Percutaneous) 124 Cardiology Consent Form Heart ‐ Cardiac Catheterization 125 Cardiology Consent Form Heart ‐ Cardiac Catheterization with Possible PCI 126 Cardiology Consent Form Heart ‐ Cardioversion 127 Cardiology Consent Form Heart ‐ Echocardiogram Transthoracic 128 Cardiology Consent Form Heart ‐ Echocardiogram with Contrast 129 Cardiology Consent Form Heart ‐ Echocardiogram With Microbubble Contrast 130 Cardiology Consent Form Heart ‐ Electrocardiogram (EKG/ECG) 131 Cardiology Consent Form Heart ‐ Electromechanical Mapping 132 Cardiology Consent Form Heart ‐ Electrophysiology Study 133 Cardiology Consent Form Heart ‐ Electrophysiology with Possible Ablation 134 Cardiology Consent Form Heart ‐ External Counterpulsation Therapy 135 Cardiology Consent Form Heart ‐ Insertion of Loop Recorder 136 Cardiology Consent Form Heart ‐ IV Fibrinolytic Therapy for STEMI 137 Cardiology Consent Form Heart ‐ Loop Recorder 138 Cardiology Consent Form Heart ‐ Positron Emission Tomography (PET) Scan for Viability 139 Cardiology Consent Form Heart ‐ Rest‐Redistribution Thallium Viability Scan 140 Cardiology Consent Form Heart ‐ Septal Puncture 141 Cardiology Consent Form Heart ‐ Stress Test ‐ Dipyridamole with MPI 142 Cardiology Consent Form Heart ‐ Stress Test ‐ Dobutamine with MPI 143 Cardiology Consent Form Heart ‐ Stress Test ‐ Exercise with MPI 144 Cardiology Consent Form Heart ‐ Stress Test Adenosine MPI 145 Cardiology Consent Form Heart ‐ Stress Test Dobutamine Echocardiogram 146 Cardiology Consent Form Heart ‐ Stress Test Exercise 147 Cardiology Consent Form Heart ‐ Stress Test Exercise Echocardiogram 148 Cardiology Consent Form Heart ‐ Stress Test Regadenoson MPI 149 Cardiology Consent Form Heart ‐ Subcutaneous ICD Placement 150 Cardiology Consent Form Heart ‐ Swan‐Ganz Catheter Placement 151 Cardiology Consent Form Heart ‐ Tilt Testing 152 Cardiology Consent Form Heart ‐ Transesophageal Cardiac Pacing 153 Cardiology Consent Form Heart ‐ Trans‐Esophageal Echocardiogram 154 Cardiology Consent Form Hemostasis Closure Device 155 Cardiology Consent Form Pericardium ‐ Pericardiocentesis 156 Cardiology Consent Form Pulmonary Artery ‐ Wedge Monitoring 157 Cardiology Consent Form Right Ventricle ‐ Biopsy 158 Cardiology Consent Form Valve ‐ Valvuloplasty (Aortic) 159 Cardiology Consent Form Valve ‐ Valvuloplasty (Mitral) 160 Care Coordination Consent Form Group Medical Appointment 161 Dentistry Consent Form Abscess ‐ Incision and Drainage (Oral) 162 Dentistry Consent Form Bronchial Tube ‐ Bronchoscopy 163 Dentistry Consent Form Bronchial Tube ‐ Bronchoscopy Rigid 164 Dentistry Consent Form Dental/Oral ‐ Alveoplasty 165 Dentistry Consent Form Dental/Oral ‐ Apicoectomy 166 Dentistry Consent Form Dental/Oral ‐ Biopsy of Soft Tissue ‐ Excision of Lesion of Mouth

167 Dentistry Consent Form Dental/Oral ‐ Cavity Filling 168 Dentistry Consent Form Dental/Oral ‐ Closure of Oral‐Antral Fistula 169 Dentistry Consent Form Dental/Oral ‐ Complete Oral Rehabilitation 170 Dentistry Consent Form Dental/Oral ‐ Core Buildup/Crown 171 Dentistry Consent Form Dental/Oral ‐ Coronectomy 172 Dentistry Consent Form Dental/Oral ‐ Cyst/Tumor Removal (Benign) 173 Dentistry Consent Form Dental/Oral ‐ Excision of Hyperplastic Tissue 174 Dentistry Consent Form Dental/Oral ‐ Exostosis and Tori Removal 175 Dentistry Consent Form Dental/Oral ‐ Extraction of Tooth (Teeth) Not Service Related 176 Dentistry Consent Form Dental/Oral ‐ Gingivoplasty/Gingivectomy 177 Dentistry Consent Form Dental/Oral ‐ Implant Placement 178 Dentistry Consent Form Dental/Oral ‐ Implant Placement (Stage 2) 179 Dentistry Consent Form Dental/Oral ‐ Implant Removal 180 Dentistry Consent Form Dental/Oral ‐ Laser‐assisted New Attachment Procedure (LANAP) 181 Dentistry Consent Form Dental/Oral ‐ Lingual Frenectomy 182 Dentistry Consent Form Dental/Oral ‐ Oral Examination 183 Dentistry Consent Form Dental/Oral ‐ Periodontal Bone Regenerative Surgery 184 Dentistry Consent Form Dental/Oral ‐ Periodontal Crown Lengthening 185 Dentistry Consent Form Dental/Oral ‐ Periodontal Flap Surgery 186 Dentistry Consent Form Dental/Oral ‐ Periodontal Gingival Augmentation Surgery 187 Dentistry Consent Form Dental/Oral ‐ Root Canal 188 Dentistry Consent Form Dental/Oral ‐ Soft Tissue Graft 189 Dentistry Consent Form Dental/Oral ‐ Tooth Extraction 190 Dentistry Consent Form Esophagus ‐ Esophagoscopy 191 Dentistry Consent Form Eyelid ‐ Blepharoplasty (Reconstructive) 192 Dentistry Consent Form Face ‐ Open Reduction Internal Fixation of Facial Fracture 193 Dentistry Consent Form Immobilizer Restraint Consent 194 Dentistry Consent Form Mandible ‐ Open Reduction Internal Fixation of Mandibular Fracture 195 Dentistry Consent Form Maxillary Sinus ‐ Nasal Antral Window (Endoscopic) 196 Dentistry Consent Form Maxillofacial ‐ Biopsy of Bone 197 Dentistry Consent Form Maxillofacial ‐ Biopsy of Bone (Needle) 198 Dentistry Consent Form Maxillofacial ‐ Blood Transfusion 199 Dentistry Consent Form Maxillofacial ‐ Bone Graft Harvest 200 Dentistry Consent Form Maxillofacial ‐ Bone Hardware Removal 201 Dentistry Consent Form Maxillofacial ‐ Cheek ‐ Zygoma Reconstruction 202 Dentistry Consent Form Maxillofacial ‐ Chin ‐ Genioplasty 203 Dentistry Consent Form Maxillofacial ‐ Closed Reduction 204 Dentistry Consent Form Maxillofacial ‐ Closed Reduction (Any Bone) 205 Dentistry Consent Form Maxillofacial ‐ ENT ‐ Consent for Procedure Not In Library 206 Dentistry Consent Form Maxillofacial ‐ Eyelid ‐ Blepharoplasty 207 Dentistry Consent Form Maxillofacial ‐ Irradiation Necrosis‐Reconstruction with Pedicle Flap 208 Dentistry Consent Form Maxillofacial ‐ Irradiation Necrosis‐Resection and Reconstruction 209 Dentistry Consent Form Maxillofacial ‐ Lip ‐ Biopsy 210 Dentistry Consent Form Maxillofacial ‐ Lip ‐ Lip Revision/Repair 211 Dentistry Consent Form Maxillofacial ‐ Lip ‐ Lip Shave 212 Dentistry Consent Form Maxillofacial ‐ Lip ‐ Plastic Repair 213 Dentistry Consent Form Maxillofacial ‐ Lip ‐ Wedge Resection 214 Dentistry Consent Form Maxillofacial ‐ Major Bone Grafts Using Hip or Rib Bone 215 Dentistry Consent Form Maxillofacial ‐ Maxillary Osteotomy 216 Dentistry Consent Form Maxillofacial ‐ Maxillary Sinus Augmentation 217 Dentistry Consent Form Maxillofacial ‐ Maxillomandibular Fixation 218 Dentistry Consent Form Maxillofacial ‐ Minor Bone Grafts Using Various Graft Types 219 Dentistry Consent Form Maxillofacial ‐ Mouth ‐ Composite Resection 220 Dentistry Consent Form Maxillofacial ‐ Mouth ‐ Palatoplasty 221 Dentistry Consent Form Maxillofacial ‐ Muscle Biopsy 222 Dentistry Consent Form Maxillofacial ‐ Nose ‐ External Lesion Excision

223 Dentistry Consent Form Maxillofacial ‐ Ortho ‐ Consent for Procedure Not In Library 224 Dentistry Consent Form Maxillofacial ‐ Parotid ‐ Biopsy 225 Dentistry Consent Form Maxillofacial ‐ Pharynx ‐ Biopsy 226 Dentistry Consent Form Maxillofacial ‐ Plastic ‐ Consent for Procedure Not In Library 227 Dentistry Consent Form Maxillofacial ‐ Sequestrectomy 228 Dentistry Consent Form Maxillofacial ‐ Sinus ‐ Endoscopic Sinusotomy 229 Dentistry Consent Form Maxillofacial ‐ Sinus ‐ Sinus Endoscopic Sinusectomy 230 Dentistry Consent Form Maxillofacial ‐ Suture of Oral/Facial Wounds + Lacerations 231 Dentistry Consent Form Maxillofacial ‐ Temporomandibular Arthroplasty 232 Dentistry Consent Form Maxillofacial ‐ Temporomandibular Joint Arthrocentesis 233 Dentistry Consent Form Maxillofacial ‐ Temporomandibular Joint Closed Manipulation 234 Dentistry Consent Form Maxillofacial ‐ Temporomandibular Joint Reconstruction 235 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Biopsy 236 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Excise Lesion with Flap 237 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Glossectomy 238 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Glossectomy with Nodes 239 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Hemiglossectomy 240 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Hemiglossectomy with Nodes 241 Dentistry Consent Form Maxillofacial ‐ Tongue ‐ Repair Frenulum 242 Dentistry Consent Form Maxillofacial ‐ Tonsil ‐ Biopsy 243 Dentistry Consent Form Maxillofacial ‐ Tonsil ‐ Post Tonsil Hemorrhage 244 Dentistry Consent Form Maxillofacial ‐ Tonsil ‐ Tonsillar Tag Removal 245 Dentistry Consent Form Maxillofacial ‐ Trachea ‐ Tracheostomy Closure 246 Dentistry Consent Form Maxillofacial ‐ Trachea ‐ Tracheostomy Revision 247 Dentistry Consent Form Maxillofacial ‐ Uvula ‐ Biopsy 248 Dentistry Consent Form Maxillofacial ‐ Vestibuloplasty 249 Dentistry Consent Form Maxillofacial ‐ Zygomatico‐Maxillary Complex and Orbital Floor Fracture Repair 250 Dentistry Consent Form Maxillofacial‐Temporomandibular Joint Arthroscopy 251 Dentistry Consent Form Nitrous Oxide and Inhalation Sedation 252 Dentistry Consent Form Nose ‐ Nasal Fracture Open Reduction 253 Dentistry Consent Form Oral Appliance Therapy for Sleep‐Related Breathing Disorders 254 Dentistry Consent Form Parotid ‐ Parotidectomy (Cancerous) 255 Dentistry Consent Form Parotid ‐ Parotidectomy (Noncancerous) 256 Dentistry Consent Form Salivary Gland ‐ Injection of Botulinum Toxin 257 Dentistry Consent Form Sinus ‐ Irrigation 258 Dentistry Consent Form Sinus ‐ Maxillary Caldwell Luc Procedure (Open) 259 Dentistry Consent Form Skin ‐ Graft Placement 260 Dentistry Consent Form Skin ‐ Melanoma Wide Excision With Possible Excision of Sentinel Node 261 Dentistry Consent Form Skin ‐ Skin Graft 262 Dentistry Consent Form Skin ‐ Skin Graft Excision 263 Dentistry Consent Form Skin ‐ Skin Lesion Excision 264 Dentistry Consent Form Skin ‐ Tissue Flap Surgery 265 Dentistry Consent Form Tampa ‐ Dental/Oral ‐ Laser Assisted New Attachment Procedure (LANAP) ® 266 Dentistry Consent Form Tongue ‐ Excise Lesion 267 Dentistry Consent Form Tongue ‐ Lesion Destruction (Cautery) 268 Dentistry Consent Form Tongue ‐ Repair 269 Dentistry Consent Form Trauma ‐ Nasal Fracture Closed Reduction 270 Dentistry Consent Form Trauma ‐ Nasal Fracture Open Reduction 271 Dentistry Consent Form Uvula ‐ Laser‐Assisted Uvulopalatoplasty 272 Dentistry Consent Form Uvula ‐ Uvulectomy 273 Dermatology Consent Form **Basic Dermatology Consent Fill‐in 274 Dermatology Consent Form Accutane 275 Dermatology Consent Form Arms ‐ Liposuction 276 Dermatology Consent Form Aspiration ‐ Fine Needle Biopsy 277 Dermatology Consent Form Bone ‐ Debridement, Open 278 Dermatology Consent Form Botulinum Toxin Injection ‐ Hyperhidrosis

279 Dermatology Consent Form Botulinum Toxin Injection ‐ Wrinkles 280 Dermatology Consent Form Electrolysis Epilation 281 Dermatology Consent Form Face ‐ Chemical Peel (Cosmetic) 282 Dermatology Consent Form Face ‐ Chemical Peel (Pre‐Malignancy) 283 Dermatology Consent Form Face ‐ Collagen Injection 284 Dermatology Consent Form Face ‐ Dermabrasion 285 Dermatology Consent Form Face ‐ Face Lift 286 Dermatology Consent Form Face ‐ Injection of L‐Poly Lactic Acid 287 Dermatology Consent Form Face ‐ Liposuction 288 Dermatology Consent Form Face ‐ Rhytidectomy Forehead 289 Dermatology Consent Form Legs ‐ Liposuction 290 Dermatology Consent Form Lip ‐ Shave 291 Dermatology Consent Form Liposuction 292 Dermatology Consent Form Removal of Nail and‐or Matrix 293 Dermatology Consent Form Skin ‐ Bioengineered Skin Substitute Placement (VA) 294 Dermatology Consent Form Skin ‐ Biopsy ‐ Punch 295 Dermatology Consent Form Skin ‐ Biopsy ‐ Shave 296 Dermatology Consent Form Skin ‐ Biopsy Incisional 297 Dermatology Consent Form Skin ‐ CO2 Laser Treatment 298 Dermatology Consent Form Skin ‐ Cryosurgery of Malignant Lesion 299 Dermatology Consent Form Skin ‐ Cryotherapy 300 Dermatology Consent Form Skin ‐ Destruction of Pre‐Malignant Lesion 301 Dermatology Consent Form Skin ‐ Electrodesiccation and Curettage 302 Dermatology Consent Form Skin ‐ Laser Treatment (Cosmetic) 303 Dermatology Consent Form Skin ‐ Laser Treatment (Vascular and Pigmented Lesions) 304 Dermatology Consent Form Skin ‐ Lesion Excision with Split Thickness Skin Graft (STSG) ‐ Benign 305 Dermatology Consent Form Skin ‐ Lesion Excision with Split Thickness Skin Graft (STSG) ‐ Malignant 306 Dermatology Consent Form Skin ‐ Melanoma Wide Excision 307 Dermatology Consent Form Skin ‐ Mohs Excision With or Without Reconstruction 308 Dermatology Consent Form Skin ‐ Photochemotherapy 309 Dermatology Consent Form Skin ‐ Photodynamic Therapy 310 Dermatology Consent Form Skin ‐ Phototherapy (UVA and UVB) 311 Dermatology Consent Form Skin ‐ Removal of Skin Tag 312 Dermatology Consent Form Skin ‐ Scar Injection with Steroid 313 Dermatology Consent Form Skin ‐ Scar Revision with or without Intraoperative Steroid Injection 314 Dermatology Consent Form Skin ‐ Scar Revision with or without Z/W Plasty or Skin Graft 315 Dermatology Consent Form Skin ‐ Thermosurgery 316 Dermatology Consent Form Skin/Muscle ‐ Mass or Lump Excision 317 Dermatology Consent Form Skin/Tissue ‐ Soft Tissue Filler Injection or Implantation 318 Dermatology Consent Form Skin/Tissue ‐ Subcutaneous Mass/Lipoma Excision 319 Dermatology Consent Form Soft Tissue ‐ Mass Excision with Biopsy (Open/Laparoscopic) 320 Dermatology Consent Form Tampa ‐ Site Marking for Dermatological Lesions Requiring Surgical Excision 321 Dermatology Consent Form Vein ‐ EVLT Laser Varicose Vein 322 Dermatology Consent Form Vein ‐ Mechanochemical Ablation of Varicose Vein 323 Dermatology Consent Form Vein ‐ Sclerotherapy Varicose Spider Veins 324 Dermatology Consent Form Wound ‐ Incision, Drainage, and Debridement 325 Emergency Medicine Administrative Leaving Against Medical Advice (AMA) 326 Emergency Medicine Administrative Provider Certification and Patient Consent for Transfer (VA FORM 10‐2649B) 327 Emergency Medicine Consent Form Abdomen ‐ Paracentesis (Possible Tube Placement) 328 Emergency Medicine Consent Form Ankle ‐ Fracture Medial Malleolar 329 Emergency Medicine Consent Form Artery ‐ Arterial Line Placement 330 Emergency Medicine Consent Form Arthrography ‐ Arthrocentesis 331 Emergency Medicine Consent Form Aspiration and/or Injection of Joint, Bursa, Cyst, or Periarticular Structure 332 Emergency Medicine Consent Form Bone ‐ Closed Reduction of Fracture 333 Emergency Medicine Consent Form Bone ‐ Intraosseous Line Placement 334 Emergency Medicine Consent Form Bone Marrow Aspiration

335 Emergency Medicine Consent Form Brain ‐ Intravenous Injection of Tissue Plasminogen Activator (tPA) 336 Emergency Medicine Consent Form Bursa ‐ Bursal Aspiration 337 Emergency Medicine Consent Form Chest ‐ Thoracentesis (VA) 338 Emergency Medicine Consent Form Computed Tomography (CT) Scan with Contrast 339 Emergency Medicine Consent Form Consent for Collection of Evidentiary Information and Materials (VA) 340 Emergency Medicine Consent Form Cornea ‐ Lesion Excision 341 Emergency Medicine Consent Form Elbow ‐ Dislocation (Closed Manipulation) 342 Emergency Medicine Consent Form General Radiology (Pregnant) 343 Emergency Medicine Consent Form Humerus ‐ Closed Reduction Humerus Shaft Fracture 344 Emergency Medicine Consent Form Joint ‐ Arthrogram (Possible Arthrocentesis) 345 Emergency Medicine Consent Form Joint ‐ Incision and Drainage 346 Emergency Medicine Consent Form Joint ‐ Injection of Joint 347 Emergency Medicine Consent Form Joint ‐ Injection of Joint with Corticosteroid 348 Emergency Medicine Consent Form Joint ‐ Manipulation with or without Injection 349 Emergency Medicine Consent Form Lumbar Puncture Specific to Newborns and Pediatrics 350 Emergency Medicine Consent Form Muscle ‐ Trigger Point Injection 351 Emergency Medicine Consent Form Muscle ‐ Trigger Point Injection with Botulinum Toxin 352 Emergency Medicine Consent Form Muscle ‐ Trigger Point Injection, EMG‐Guided 353 Emergency Medicine Consent Form Penis ‐ Priapism Aspiration and Irrigation 354 Emergency Medicine Consent Form Peripheral Nerve Block 355 Emergency Medicine Consent Form Pharynx ‐ Nasopharyngoscopy 356 Emergency Medicine Consent Form Pilonidal Cyst Incision and Drainage 357 Emergency Medicine Consent Form Removal of Foreign Body ‐ Complex 358 Emergency Medicine Consent Form Shoulder ‐ Reduction of Dislocated Shoulder 359 Emergency Medicine Consent Form Soft Tissue ‐ Incision and Drainage 360 Emergency Medicine Consent Form Soft Tissue ‐ Laceration Suture Repair 361 Emergency Medicine Consent Form Spine ‐ Lumbar Puncture 362 Emergency Medicine Consent Form Vein ‐ Central Line Placement 363 Emergency Medicine Consent Form Vein ‐ Central Venous Catheter Removal 364 Emergency Medicine Consent Form Vein ‐ Intravenous Injection of Contrast Medium 365 Emergency Medicine Consent Form Wound ‐ Intermediate Repair 366 Family Medicine Consent Form Vulva ‐ Bartholin Cyst Marsupialization 367 Gastroenterology Consent Form Anorectal Manometry 368 Gastroenterology Consent Form Anoscopy/Proctoscopy with Possible Interventions 369 Gastroenterology Consent Form Anus ‐ High Resolution Anoscopy with Possible Interventions (VA) 370 Gastroenterology Consent Form Anus ‐ Injection of Bulking Agent 371 Gastroenterology Consent Form Biliary ‐ Cholecystostomy Tube Removal 372 Gastroenterology Consent Form Biologic Infusion Therapy 373 Gastroenterology Consent Form Botox Injection Therapy Anal Fissures 374 Gastroenterology Consent Form Capsule Endoscopy 375 Gastroenterology Consent Form Colon ‐ Colonoscopy 376 Gastroenterology Consent Form Colon ‐ Colonoscopy + Flexible Sigmoidoscopy 377 Gastroenterology Consent Form Colon ‐ Colonoscopy with Hemorrhoid Banding 378 Gastroenterology Consent Form Colon ‐ Colonoscopy with Sclerotherapy 379 Gastroenterology Consent Form Colonoscopy Decompression (VA) 380 Gastroenterology Consent Form Colonoscopy EUS (VA) 381 Gastroenterology Consent Form Colonoscopy Stent (VA) 382 Gastroenterology Consent Form Colonoscopy with Interventions Moderate Sedation 383 Gastroenterology Consent Form Colonoscopy with Possible Interventions (VA) 384 Gastroenterology Consent Form EGD and Colonoscopy EUS (VA) 385 Gastroenterology Consent Form EGD and Colonoscopy with Possible Interventions (VA) 386 Gastroenterology Consent Form EGD Botox (VA) 387 Gastroenterology Consent Form EGD EUS (VA) 388 Gastroenterology Consent Form EGD EUS Cyst Drain (VA) 389 Gastroenterology Consent Form EGD PEG/PEG Tube Removal and/or Replacement (VA) 390 Gastroenterology Consent Form EGD PEG/PEJ Tube (VA)

391 Gastroenterology Consent Form EGD Stent (VA) 392 Gastroenterology Consent Form EGD Wireless pH Monitor (VA) 393 Gastroenterology Consent Form EGD with Possible Interventions (VA) 394 Gastroenterology Consent Form EGD with Radiofrequency Ablation of Barrett's Mucosa (VA) 395 Gastroenterology Consent Form Enteroscopy 396 Gastroenterology Consent Form Enteroscopy with Possible Interventions (VA) 397 Gastroenterology Consent Form ERCP with Possible Interventions (VA) 398 Gastroenterology Consent Form Esophageal Capsule Endoscopy (VA) 399 Gastroenterology Consent Form Esophageal Dilation 400 Gastroenterology Consent Form Esophageal Manometry (VA) 401 Gastroenterology Consent Form Esophageal Manometry with pH Probe 402 Gastroenterology Consent Form Esophagus ‐ Catheter‐based pH Test (with or without Impedance) 24 Hour 403 Gastroenterology Consent Form Esophagus ‐ Endoscopic Retrograde Cholangiopancreatography (ERCP) with Papillotomy 404 Gastroenterology Consent Form Esophagus ‐ Endoscopic Ultrasound of the Upper GI Tract 405 Gastroenterology Consent Form Esophagus ‐ Esophagogastroduodenoscopy (EGD) w/ Possible Campylobacter‐like Organisms (CLO) Test 406 Gastroenterology Consent Form Esophagus ‐ Esophagogastroduodenoscopy (EGD) with Banding 407 Gastroenterology Consent Form Esophagus ‐ Esophagogastroduodenoscopy (EGD) with Variceal Injection 408 Gastroenterology Consent Form Esophagus/Colon ‐ Esophagogastroduodenoscopy (EGD) and Endoscopic Colorectal Ultrasound 409 Gastroenterology Consent Form EUS with Possible Interventions (VA) 410 Gastroenterology Consent Form EUS/ERCP (VA) 411 Gastroenterology Consent Form Fecal Microbiota Transplantation for C. Difficile Infection (VA) 412 Gastroenterology Consent Form Flexible Sigmoidoscopy 413 Gastroenterology Consent Form Functional/Pain ‐ Botulinum Toxin Injection 414 Gastroenterology Consent Form Gastrointestinal (GI) Transit Capsule Study 415 Gastroenterology Consent Form Gastrostomy Tube Placement Open 416 Gastroenterology Consent Form Gastrostomy Tube Removal 417 Gastroenterology Consent Form Hemorrhoid Banding 418 Gastroenterology Consent Form Jejunostomy Tube Placement (Laparoscopic Possible Open) 419 Gastroenterology Consent Form Jejunostomy Tube Placement (Open) 420 Gastroenterology Consent Form Jejunostomy Tube Placement (PEJ) 421 Gastroenterology Consent Form Large Volume Abdominal Paracentesis (VA) 422 Gastroenterology Consent Form Liver ‐ Needle Biopsy (Mass or Tumor) 423 Gastroenterology Consent Form Liver ‐ Needle Biopsy (Non‐Tumor) 424 Gastroenterology Consent Form Nodes/Abdomen/Pelvis ‐ Retroperitoneal Lymphadenectomy (Open) 425 Gastroenterology Consent Form Patency Capsule (VA) 426 Gastroenterology Consent Form PEG Tube Replacement without EGD 427 Gastroenterology Consent Form Percutaneous Liver Biopsy (VA) 428 Gastroenterology Consent Form Rectum ‐ Rectal Exam Under Anesthesia 429 Gastroenterology Consent Form Sigmoidoscopy 430 Gastroenterology Consent Form Small Bowel Capsule Endoscopy (VA) 431 Gastroenterology Consent Form Stomach ‐ Biliopancreatic Diversion 432 Gastroenterology Consent Form Stomach ‐ Biliopancreatic Diversion with Duodenum Switch 433 Gastroenterology Consent Form Stomach ‐ Closure of Gastrocutaneous Fistula 434 Gastroenterology Consent Form Stomach ‐ Distal Gastric Bypass 435 Gastroenterology Consent Form Stomach ‐ Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement 436 Gastroenterology Consent Form Stomach ‐ Roux‐en‐Y Gastric Bypass (Laparoscopic) 437 Gastroenterology Consent Form Tampa ‐ Procto‐Sigmoidoscopy 438 Gastroenterology Consent Form Therapeutic Phlebotomy 439 Gastroenterology Consent Form Trachea ‐ Tracheoesophageal Fistula Repair 440 Gastroenterology Consent Form Upper Gastrointestinal Series 441 General Surgery Consent Form Abdomen ‐ Abdominal/Pelvic Exam Under Anesthesia (Female) with Possible Interventions 442 General Surgery Consent Form Abdomen ‐ Abdominal/Pelvic Exam Under Anesthesia (Male) with Possible Interventions 443 General Surgery Consent Form Abdomen ‐ Components Separation Repair (Laparoscopic Possible Open) 444 General Surgery Consent Form Abdomen ‐ Components Separation Repair (Open) 445 General Surgery Consent Form Abdomen ‐ Drain Placement Abscess 446 General Surgery Consent Form Abdomen ‐ Epigastric Hernia Repair (Lap/Open)

447 General Surgery Consent Form Abdomen ‐ Excision of Abdominal Wall Tumor or Mass 448 General Surgery Consent Form Abdomen ‐ Hematoma Evacuation (Intra‐Abdominal) 449 General Surgery Consent Form Abdomen ‐ Hernia Epigastric Repair (Robotic‐Assisted Laparoscopic Possible Open) 450 General Surgery Consent Form Abdomen ‐ Hernia Femoral Repair 451 General Surgery Consent Form Abdomen ‐ Hernia Incisional Repair ‐ Laparoscopic 452 General Surgery Consent Form Abdomen ‐ Hernia Incisional Repair ‐ Open 453 General Surgery Consent Form Abdomen ‐ Hernia Parastomal Repair (Laparoscopic Possible Open) 454 General Surgery Consent Form Abdomen ‐ Hernia Repair ‐ Ventral or Incisional ‐ Possible Mesh and/or Plug (Laparoscopic Possible Open) 455 General Surgery Consent Form Abdomen ‐ Hernia Repair ‐ Ventral or Incisional ‐ Possible Mesh and/or Plug (Open) 456 General Surgery Consent Form Abdomen ‐ Hernia Repair ‐ Ventral or Incisional ‐ Possible Mesh and/or Plug (Robotic‐Assisted Laparoscopic Possible Open) 457 General Surgery Consent Form Abdomen ‐ Hernia Umbilical Repair ‐ Open 458 General Surgery Consent Form Abdomen ‐ Hernia Umbilical Repair (Laparoscopic) 459 General Surgery Consent Form Abdomen ‐ Hernia Umbilical Repair (Open) 460 General Surgery Consent Form Abdomen ‐ Hernia Umbilical Repair (Robotic‐Assisted Laparoscopic Possible Open) 461 General Surgery Consent Form Abdomen ‐ Hernia Ventral Repair ‐ Laparoscopic (Possible Mesh) 462 General Surgery Consent Form Abdomen ‐ Hernia Ventral Repair ‐ Open (Possible Mesh) 463 General Surgery Consent Form Abdomen ‐ Laparoscopy with Possible Laparotomy 464 General Surgery Consent Form Abdomen ‐ Laparotomy (Exploratory / Trauma) with Possible Interventions 465 General Surgery Consent Form Abdomen ‐ Laparotomy (Exploratory) with Possible Biopsy 466 General Surgery Consent Form Abdomen ‐ Laparotomy (Exploratory) with Tumor Debulking 467 General Surgery Consent Form Abdomen ‐ Liver Biopsy with Possible Interventions (Laparoscopic Possible Open) 468 General Surgery Consent Form Abdomen ‐ Liver Biopsy with Possible Interventions (Open) 469 General Surgery Consent Form Abdomen ‐ Lysis of Adhesions (Laparoscopic Possible Open) 470 General Surgery Consent Form Abdomen ‐ Lysis of Adhesions (Open) 471 General Surgery Consent Form Abdomen ‐ Mesh Removal 472 General Surgery Consent Form Abdomen ‐ Ostomy Takedown (Laparoscopic Possible Open) 473 General Surgery Consent Form Abdomen ‐ Ostomy Takedown (Open) 474 General Surgery Consent Form Abdomen ‐ Parastomal Hernia Repair 475 General Surgery Consent Form Abdomen ‐ Retroperitoneal Exploration 476 General Surgery Consent Form Abdomen/Chest ‐ Escharotomy 477 General Surgery Consent Form Abdomen/Pelvis ‐ Diagnostic Laparoscopy 478 General Surgery Consent Form Ankle ‐ Amputation (Boyd or Pirogoff) 479 General Surgery Consent Form Anus ‐ Anal Biopsy 480 General Surgery Consent Form Anus ‐ Anal Dilation 481 General Surgery Consent Form Anus ‐ Anal Fistula Repair 482 General Surgery Consent Form Anus ‐ Anal Fistulectomy 483 General Surgery Consent Form Anus ‐ Anal Fistulotomy 484 General Surgery Consent Form Anus ‐ Anal Lesion Excision 485 General Surgery Consent Form Anus ‐ Anal Sphincteroplasty 486 General Surgery Consent Form Anus ‐ Anal Sphincterotomy 487 General Surgery Consent Form Anus ‐ Chemodenervation of Internal Anal Sphincter with Botulinum Toxin 488 General Surgery Consent Form Anus ‐ Condyloma Fulguration 489 General Surgery Consent Form Anus ‐ Hemorrhoid Stapling 490 General Surgery Consent Form Anus ‐ Hemorrhoidectomy 491 General Surgery Consent Form Appendix ‐ Appendectomy (Laparoscopic) 492 General Surgery Consent Form Appendix ‐ Appendectomy (Open) 493 General Surgery Consent Form Artery ‐ Atherectomy ‐ Above Aortic Arch 494 General Surgery Consent Form Artery ‐ Atherectomy ‐ Below Aortic Arch 495 General Surgery Consent Form Artery ‐ Embolization 496 General Surgery Consent Form Artery ‐ Lysis ‐ Above Aortic Arch 497 General Surgery Consent Form Artery ‐ Lysis ‐ Below Aortic Arch 498 General Surgery Consent Form Bile Ducts ‐ Common Duct Exploration (Lap/Open) 499 General Surgery Consent Form Bile Ducts ‐ Intraoperative Cholangiogram 500 General Surgery Consent Form Bladder/Colon ‐ Colovesical Fistula Repair 501 General Surgery Consent Form Breast ‐ Breast Reconstruction Revision 502 General Surgery Consent Form Breast ‐ Capsulotomy

503 General Surgery Consent Form Breast ‐ Duct Excision 504 General Surgery Consent Form Breast ‐ Excision of Lesion, Mass, or Tumor 505 General Surgery Consent Form Breast ‐ Mastectomy Modified Radical 506 General Surgery Consent Form Breast ‐ Mastectomy Radical 507 General Surgery Consent Form Breast ‐ Mastectomy Simple (Cancerous) 508 General Surgery Consent Form Breast ‐ Mastotomy with Biopsy 509 General Surgery Consent Form Breast ‐ Needle Localization (for Biopsy, Preoperative, or Intraoperative) 510 General Surgery Consent Form Breast ‐ Nipple Reconstruction 511 General Surgery Consent Form Breast ‐ Nipple Removal 512 General Surgery Consent Form Breast ‐ Prophylactic Mastectomy Simple (Noncancerous) 513 General Surgery Consent Form Breast ‐ Reconstruction with Tissue Expander 514 General Surgery Consent Form Breast ‐ Reduction Mammoplasty (Reconstructive) 515 General Surgery Consent Form Breast ‐ Reduction Mammoplasty Male (Cosmetic) 516 General Surgery Consent Form Chest ‐ Vascular Access (Removal) 517 General Surgery Consent Form Chest ‐ Vascular Access (Revision) 518 General Surgery Consent Form Chest Wall ‐ Biopsy of Chest Wall 519 General Surgery Consent Form Chest Wall ‐ Evacuation of Chest Wall Hematoma 520 General Surgery Consent Form Colon ‐ Abdominal Colectomy Total with Ileorectal Anastomosis and Possible Ileostomy (Cancerous) (Robotic‐Assisted Laparoscopic Possible Open) 521 General Surgery Consent Form Colon ‐ Colectomy ‐ Hemi ‐ Laparoscopic 522 General Surgery Consent Form Colon ‐ Colectomy ‐ Hemi ‐ Open 523 General Surgery Consent Form Colon ‐ Colectomy ‐ Subtotal ‐ Open 524 General Surgery Consent Form Colon ‐ Colectomy ‐ Total ‐ Laparoscopic 525 General Surgery Consent Form Colon ‐ Colectomy ‐ Total ‐ Open 526 General Surgery Consent Form Colon ‐ Colectomy ‐ Total Abdominal without Proctectomy + with Ileostomy 527 General Surgery Consent Form Colon ‐ Colectomy ‐ Total Noncancerous ‐ LapOpen 528 General Surgery Consent Form Colon ‐ Colectomy (Partial/Total) Possible Proctectomy (Partial/Total) w/Ileostomy (Lap/Open) 529 General Surgery Consent Form Colon ‐ Colectomy Colostomy Hartmann's 530 General Surgery Consent Form Colon ‐ Colectomy Partial w/ Colostomy (Lap/Open) 531 General Surgery Consent Form Colon ‐ Colectomy Segmental (Cancerous) (Laparoscopic) 532 General Surgery Consent Form Colon ‐ Colectomy Segmental (Cancerous) (Open) 533 General Surgery Consent Form Colon ‐ Colectomy Segmental (Noncancerous) (Laparoscopic) 534 General Surgery Consent Form Colon ‐ Colectomy Segmental (Noncancerous) (Open) 535 General Surgery Consent Form Colon ‐ Colectomy Total with Ileostomy (Cancerous) (Laparoscopic) 536 General Surgery Consent Form Colon ‐ Colectomy Total with Ileostomy (Cancerous) (Open) 537 General Surgery Consent Form Colon ‐ Colectomy Total with Ileostomy (Noncancerous) (Laparoscopic) 538 General Surgery Consent Form Colon ‐ Colectomy Total with Ileostomy (Noncancerous) (Open) 539 General Surgery Consent Form Colon ‐ Colectomy Total with Ileostomy (Noncancerous) (Robotic‐Assisted Laparoscopic Possible Open) 540 General Surgery Consent Form Colon ‐ Colostomy (Laparoscopic Possible Open) 541 General Surgery Consent Form Colon ‐ Colostomy (Open) 542 General Surgery Consent Form Colon ‐ Colostomy Revision 543 General Surgery Consent Form Colon ‐ Diverting Colostomy 544 General Surgery Consent Form Colon ‐ Extended Transverse Colectomy 545 General Surgery Consent Form Colon ‐ Rigid Sigmoidoscopy 546 General Surgery Consent Form Colon ‐ Takedown of Splenic Flexure 547 General Surgery Consent Form Colon/Rectum ‐ Abdominoperineal Resection 548 General Surgery Consent Form Copy of Peritoneal Cavity ‐ Removal of Peritoneal Catheter 549 General Surgery Consent Form Duodenum ‐ Duodenal Resection 550 General Surgery Consent Form Esophagus ‐ Distal Esophagectomy 551 General Surgery Consent Form Esophagus ‐ Esophagectomy ‐ Cancerous 552 General Surgery Consent Form Esophagus ‐ Esophagogastrectomy (Cancerous) (Laparoscopic Possible Open) 553 General Surgery Consent Form Esophagus ‐ Esophagogastrectomy (Cancerous) (Open) 554 General Surgery Consent Form Esophagus ‐ Fundoplication (Laparoscopic Possible Open) 555 General Surgery Consent Form Esophagus ‐ Fundoplication (Open) 556 General Surgery Consent Form Esophagus ‐ Fundoplication (Robotic‐Assisted Laparoscopic Possible Open) 557 General Surgery Consent Form Esophagus ‐ Heller Myotomy 558 General Surgery Consent Form Esophagus ‐ Heller Myotomy (Robotic‐Assisted Laproscopic/Thoracoscopic Possible Open)

559 General Surgery Consent Form Esophagus ‐ Transhiatal Esophagogastrectomy (Robotic‐Assisted Laparoscopic Possible Open) 560 General Surgery Consent Form Esophagus‐ Esophagogastrectomy 561 General Surgery Consent Form Exploration of Surgical Site for Hemorrhage 562 General Surgery Consent Form Extremity ‐ Amputation Formalization (Amputation Revision) 563 General Surgery Consent Form Extremity ‐ Escharotomy 564 General Surgery Consent Form Finger ‐ Amputation 565 General Surgery Consent Form Gall Bladder ‐ Cholecystectomy (Laparoscopic) 566 General Surgery Consent Form Gall Bladder ‐ Cholecystectomy (Open) 567 General Surgery Consent Form Gall Bladder ‐ Cholecystectomy (Open) w/CDE 568 General Surgery Consent Form Gallbladder ‐ Cholecystectomy (Robotic‐Assisted Laparoscopic Possible Open) 569 General Surgery Consent Form Gallbladder ‐ Cholecystectomy with Possible Biliary Drainage (Laparoscopic Possible Open) 570 General Surgery Consent Form Gallbladder ‐ Cholecystectomy with Possible Biliary Drainage (Open) 571 General Surgery Consent Form Gastrointestinal ‐ Gastrostomy Tube Placement 572 General Surgery Consent Form Groin ‐ Hernia Inguinal Repair (Laparoscopic) 573 General Surgery Consent Form Groin ‐ Hernia Inguinal Repair (Open) 574 General Surgery Consent Form Groin Exploration (Female) 575 General Surgery Consent Form Groin Exploration (Male) 576 General Surgery Consent Form Hyperbaric Oxygen Treatment for Wound Care 577 General Surgery Consent Form Implantable Infusion Port Placement 578 General Surgery Consent Form Implantable Infusion Port Removal 579 General Surgery Consent Form Injection of Lesion 580 General Surgery Consent Form Jejunostomy ‐ J‐tube (Open) 581 General Surgery Consent Form Kidney ‐ Adrenalectomy (Cancerous) (Laparoscopic Possible Open) 582 General Surgery Consent Form Kidney ‐ Adrenalectomy (Cancerous) (Open) 583 General Surgery Consent Form Kidney ‐ Adrenalectomy (Cancerous) (Robotic‐Assisted Laparoscopic Possible Open) 584 General Surgery Consent Form Kidney ‐ Adrenalectomy (Noncancerous) (Laparscopic Possible Open) 585 General Surgery Consent Form Kidney ‐ Adrenalectomy (Noncancerous) (Open) 586 General Surgery Consent Form Kidney ‐ Adrenalectomy (Noncancerous) (Robotic‐Assisted Laparoscopic Possible Open) 587 General Surgery Consent Form Kidney ‐ Surgical Biopsy (Lap, Open) 588 General Surgery Consent Form Leg ‐ Above Knee Amputation 589 General Surgery Consent Form Leg ‐ Amputation at Knee Joint 590 General Surgery Consent Form Leg ‐ Amputation Revision 591 General Surgery Consent Form Leg ‐ Below Knee Amputation (BKA) 592 General Surgery Consent Form Liver ‐ Cryoablation of Tumor (Percutaneous) 593 General Surgery Consent Form Liver ‐ Hepatectomy (Right or Left) 594 General Surgery Consent Form Liver ‐ Hepatic Trisegmentectomy 595 General Surgery Consent Form Liver ‐ Hepatic Wedge Resection 596 General Surgery Consent Form Liver ‐ Liver Resection 597 General Surgery Consent Form Liver ‐ Removal of Hepatic Arterial Infusion (HAI) Pump 598 General Surgery Consent Form Lung ‐ Biopsy 599 General Surgery Consent Form Lung ‐ Cryoablation of Tumor (Percutaneous) 600 General Surgery Consent Form Lung ‐ Lobectomy 601 General Surgery Consent Form Lymph Nodes ‐ Biopsy and Excision (Without Mapping) 602 General Surgery Consent Form Lymph Nodes ‐ Dissection 603 General Surgery Consent Form Lymph Nodes ‐ Mapping and Biopsy 604 General Surgery Consent Form Lymph Nodes ‐ Needle Biopsy 605 General Surgery Consent Form Mucous Membrane ‐ Lesion Excision with Defect Repair (Cancerous) 606 General Surgery Consent Form Mucous Membrane ‐ Lesion Excision with Defect Repair (Noncancerous) 607 General Surgery Consent Form Muscle ‐ Biopsy 608 General Surgery Consent Form Neck ‐ Escharotomy 609 General Surgery Consent Form Neck ‐ Exploration for Trauma 610 General Surgery Consent Form Neck/Groin ‐ Implantable Infusion Port Revision 611 General Surgery Consent Form Neuroma ‐ Scar Neuroma Injection 612 General Surgery Consent Form Nodes Pelvic ‐ Pelvic Lymphadenectomy (Laparoscopic) 613 General Surgery Consent Form Nodes Pelvic ‐ Pelvic Lymphadenectomy (Open) 614 General Surgery Consent Form Nodes/Abdomen/Pelvis ‐ Retroperitoneal Lymphadenectomy (Laparoscopic)

615 General Surgery Consent Form Omentum ‐ Omentectomy (Laparoscopic) 616 General Surgery Consent Form Pancreas ‐ Cystogastrostomy and Cystenterostomy (Laparoscopic) 617 General Surgery Consent Form Pancreas ‐ Cystogastrostomy and Cystenterostomy (Open) 618 General Surgery Consent Form Pancreas ‐ Excision of Ampulla 619 General Surgery Consent Form Pancreas ‐ Pancreatectomy (Laparoscopic or Open) 620 General Surgery Consent Form Pancreas ‐ Pancreaticoduodenectomy 621 General Surgery Consent Form Pancreas ‐ Pancreaticoduodenectomy (Laparoscopic Possible Open) 622 General Surgery Consent Form Pancreas ‐ Pancreaticojejunostomy 623 General Surgery Consent Form Parathyroid ‐ Parathyroidectomy (Cancerous) 624 General Surgery Consent Form Parathyroid ‐ Parathyroidectomy (Noncancerous) 625 General Surgery Consent Form Percutaneous Absolute Alcohol Ablation of Tumor 626 General Surgery Consent Form Percutaneous Radiofrequency Ablation of Hepatic Tumor 627 General Surgery Consent Form Percutaneous Radiofrequency Ablation of Tumor 628 General Surgery Consent Form Peritoneal Cavity ‐ Intraperitoneal Catheter Insertion Laparoscopic or Open 629 General Surgery Consent Form Peritoneal Cavity ‐ Open Intraperitoneal Catheter Insertion 630 General Surgery Consent Form Peritoneal Cavity ‐ Removal of Peritoneal Catheter 631 General Surgery Consent Form Peritoneum ‐ Other Lysis of Peritoneal Adhesions 632 General Surgery Consent Form Pharynx ‐ Crico‐Pharyngeal Myotomy 633 General Surgery Consent Form Pilonidal Cyst Excision 634 General Surgery Consent Form Pleura ‐ Pleural Biopsy 635 General Surgery Consent Form Rectum ‐ Abdominoperineal Resection (Cancerous) (Laparoscopic Possible Open) 636 General Surgery Consent Form Rectum ‐ Abdominoperineal Resection (Cancerous) (Open) 637 General Surgery Consent Form Rectum ‐ Abdominoperineal Resection (Cancerous) (Robotic‐Assisted Laparoscopic Possible Open) 638 General Surgery Consent Form Rectum ‐ Abdominoperineal Resection (Noncancerous) (Laparoscopic Possible Open) 639 General Surgery Consent Form Rectum ‐ Abdominoperineal Resection (Noncancerous) (Open) 640 General Surgery Consent Form Rectum ‐ Abdominoperineal Resection (Noncancerous) (Robotic‐Assisted Laparoscopic Possible Open) 641 General Surgery Consent Form Rectum ‐ Completion Proctectomy 642 General Surgery Consent Form Rectum ‐ Fecal Impaction 643 General Surgery Consent Form Rectum ‐ Low Anterior Resection (Laparoscopic/Open) 644 General Surgery Consent Form Rectum ‐ Lower Anterior Resection for Cancer (Laparoscopic Possible Open) 645 General Surgery Consent Form Rectum ‐ Lower Anterior Resection for Cancer (Open) 646 General Surgery Consent Form Rectum ‐ Lower Anterior Resection for Cancer (Robotic‐Assisted Laparoscopic Possible Open) 647 General Surgery Consent Form Rectum ‐ Lower Anterior Resection for Prolapse (Laparoscopic Possible Open) 648 General Surgery Consent Form Rectum ‐ Lower Anterior Resection for Prolapse (Open) 649 General Surgery Consent Form Rectum ‐ Lower Anterior Resection for Prolapse (Robotic‐Assisted Laparoscopic Possible Open) 650 General Surgery Consent Form Rectum ‐ Rectal Biopsy 651 General Surgery Consent Form Rectum ‐ Rectocele Repair 652 General Surgery Consent Form Rectum ‐ Transanal Resection 653 General Surgery Consent Form Resection of First or Cervical Rib 654 General Surgery Consent Form Rib ‐ Plating Fracture 655 General Surgery Consent Form Scalenectomy 656 General Surgery Consent Form Self‐Administration of Medication/Patient‐controlled analgesia 657 General Surgery Consent Form Sigmoid Colon ‐ Sigmoid Resection 658 General Surgery Consent Form Skeletal Exam Under Anesthesia 659 General Surgery Consent Form Skin ‐ Soft Tissue Mass Excision 660 General Surgery Consent Form Small Intestine ‐ Small Bowel Resection (Cancerous) (Laparoscopic Possible Open) 661 General Surgery Consent Form Small Intestine ‐ Small Bowel Resection (Cancerous) (Open) 662 General Surgery Consent Form Small Intestine ‐ Small Bowel Resection (Cancerous) (Robotic‐Assisted Laparoscopic Possible Open) 663 General Surgery Consent Form Small Intestine ‐ Small Bowel Resection (Noncancerous) (Laparoscopic Possible Open) 664 General Surgery Consent Form Small Intestine ‐ Small Bowel Resection (Noncancerous) (Open) 665 General Surgery Consent Form Small Intestine ‐ Small Bowel Resection (Noncancerous) (Robotic‐Assisted Laparoscopic Possible Open) 666 General Surgery Consent Form Spleen ‐ Splenectomy ‐ Open 667 General Surgery Consent Form Spleen ‐ Splenectomy (Cancerous) (Laparoscopic Possible Open) 668 General Surgery Consent Form Spleen ‐ Splenectomy (Cancerous) (Robotic‐Assisted Laparoscopic Possible Open) 669 General Surgery Consent Form Spleen ‐ Splenectomy (Noncancerous) (Laparoscopic Possible Open) 670 General Surgery Consent Form Spleen ‐ Splenectomy (Noncancerous) (Open)

671 General Surgery Consent Form Spleen ‐ Splenectomy (Noncancerous) (Robotic‐Assisted Laparoscopic Possible Open) 672 General Surgery Consent Form Spleen ‐ Splenorrhaphy Possible Splenectomy 673 General Surgery Consent Form Stomach ‐ Gastrectomy (Cancerous) (Laparoscopic) 674 General Surgery Consent Form Stomach ‐ Gastrectomy (Cancerous) (Open) 675 General Surgery Consent Form Stomach ‐ Gastrectomy (Cancerous) (Robotic‐Assisted Laparoscopic Possible Open) 676 General Surgery Consent Form Stomach ‐ Gastrectomy (Noncancerous) (Laparoscopic) 677 General Surgery Consent Form Stomach ‐ Gastrectomy (Noncancerous) (Open) 678 General Surgery Consent Form Stomach ‐ Gastrectomy (Noncancerous) (Robotic‐Assisted Laparoscopic Possible Open) 679 General Surgery Consent Form Stomach ‐ Gastrectomy Subtotal ‐ Laparoscopic 680 General…