New Client Consultation Form

New York State, Medicare and all ambulatory accrediting agencies mandate that patients be accompanied by a responsible adult 18 years of age or older when leaving the facility. This is for patient safety.

Patients cannot Drive or operate heavy equipment for 48 hours following their procedure or in any case if under the influence of narcotic medications for pain management.

Your escort must be available to receive instructions regarding your care following your procedure and sign the discharge forms.

Chaperone name

First Name Last Name

Chaperone telephone

Area Code Phone Number

I understand the above requirements and I authorize the surgical center, in case my escort is not present or for any reason unavailable at the time of my discharge, to arrange for:

Choose one option:

A member of the Surgical Center staff to bring me at home and pay the Surgical Center $100.00 plus transportation to and from my house because my escort is waiting for me at home. A member of the Surgical Center staff to bring me at home and stay with me overnight and pay directly the staff member $400.00 plus transportation to and from my house. I understand that the staff member provided has no medical background. This arrangement is between me and the staff member and the Surgical Center cannot be held responsible for any issue that may arise including but not limited to personal injuries. This arrangement has to be made prior to surgery and available only if there is a staff member willing to accommodate. “The Discreet Medical Chaperone” service. Non-medical personnel provide this service and the charges for this service is $40.00 per hour with a minimum of 2 hours plus transportation to and from my house. This service provides an overnight stay at the above-mentioned rate. Service outside New York City is priced on a case-by-case basis. I understand that this service accept only cash or personal check payments.

Signature *

Clear

Name *

First Name Last Name

Date *

Date

Discharge and Escort Policy