ASC Procedure Instructions & Forms

Endoscopy - Advanced Directives

Clinical Associates Ambulatory Surgery Center is a center performing only non-emergency outpatient endoscopy procedures.

It is our policy at Clinical Associates Ambulatory Surgery Center not to acknowledge Advance Directives of any person while in our facility. In the event of an emergency situation the person will be transferred to a hospital via 911.

I hereby acknowledge receipt of the Brochure titled "Information About Your Outpatient Visit" and understand the above information.



Patient Name:  
Patient Signature:
(name in corresponding box will act as signature)
Date:
Signature of Representative/Relationship:
(name in corresponding box will act as signature)
Date:
Witness Signature:
(name in corresponding box will act as signature)
Date: