Financial Agreement | Private Autopsy Services

CONSENT FORM

CASE NO.
DECEDENT’S NAME:
First Middle Last
Date of Birth:
Date of Death:
Approx. Weight:
Approx. Height:
inches
Ethnicity:
Funeral Home:
Phone
Next-of-Kin:
First Middle Last
Second Name ( Optional )
Email
Phone:
Home Address:
Street Address Address Line 2 City State ZIP Code
1). I certify that I am the
and have the right to control the disposition of the remains of said decedent. I hereby authorize and contract you, together and with your assistants to perform a
(procedure)
of such deceased and the removal of such structures or organs as you may deem necessary along with the collection of body fluids for special analysis. Body fluids will be collected a the Pathologist’s discretion and stored/refrigerated for 30 days following the postmortem procedure. If the specimens are not utilized within the time frame they will be discarded unless alternate arrangements have been made prior. IF TOXICOLOGY ANALYSIS IS NECESSARY THERE WILL BE AN ADDITIONAL CHARGE. A one quart stock container of tissue specimens, microscopic slides, histology cassettes, autopsy report, and photographs (if taken) will be archived for two years from date of autopsy after which they will be properly disposed of in accordance with CAL/OSHA blood borne pathogens standards.
2). I also authorize any cemetery authority, licensed funeral director or licensed hospital, having custody of such remains, to permit or assist such postmortem procedure, including transportation of the remains to/from the hospital or mortuary as may be arranged by you for such postmortem services. In the event of any third party, myself, my heirs, executors, or adminstrators should attempt to sue
(Patholgist name)

(This text field will auto-fill the lower two pathologist names.)
or any of his/her employees, agents, associates, representatives, or subcontractors (collectively, the “providers”) for any cause of action, including negligence or emotional distress, arising from the above-described services, I hereby agree to hold the Providers harmless and indemnify them for any and all claims for damages, demands, collections, and actions whatsoever, including all costs, court appearances, and attorney’s fees that may be incurred.
3). Second-opinion Autopsy reports will not be released until Pathologist receives the Final Autopsy Report from the Medical Examiner’s Office and/or Hospital where original autopsy was performed.
4). The decedent will be transported to APS, Inc. morgue facility located at 5134 Valley Blvd. Los Angeles, CA 90032 for a postmortem procedure and upon completion will be returned to:
Funeral Home Return Address
Street Address Address Line 2 City State ZIP Code
1. (Autopsy procedure):
$
2. (Tissue/DNA/Appliance procurement)
$
3). Transportation/Shipping:
4). Toxicology Analysis:
5). Neurological Diagnosis (Brain-Only Autopsy):
6). Mesothelioma Diagnosis (Lung-Only Autopsy):
7). X-Ray:
8). Credit Card Surcharge 2.5%
TOTAL:
Financial Agreement:
1). The undersigned recognized that the Pathologist furnishing services to the decedent/family is an independent contractor and is not an employee or agent of 1-800-AUTOPSY/Autopsy Post Services, Inc. Please be advised that the total cost for postmortem procedure must be paid to the order of
(Pathologist)

(The pathologist name will be auto-filled from above.)
2). The undersigned agrees, in consideration of services rendered, that he/she individually obligate himself/herself to pay the amount in accordance with the rates and terms. Should the account be referred to an attorney or collection, the undersigned shall pay reasonable attorney’s fees, court fees and collection expenses. All delinquent account bear interest at the legal rate.

3). Photographs are not automatically returned to families with completed report unless specifically requested due to the graphic nature and subject matter. We will forward photographs to a designated person upon written request.

4). If Toxicology analysis is necessary there will be an additional charge.

5). If paying with a credit card, there will be an additional surcharge of 2.5%.

6). This contract provides for postmortem services only. It does not retain the Pathologist as an expert witness.
7). Make Cashier’s Checks payable to
Pathologist and total fee listed above. The pathologist name will be auto-filled from above.

Pathologist and total fee listed above. The pathologist name will be auto-filled from above.

CONSENT FORM

Next-of-Kin:

Financial Agreement:

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