Informed Consent Form Template

INFORMED CONSENT FOR MEDICAL TREATMENT

Date: Date

Healthcare Provider: Provider Name/Facility Name

Address: Facility Address Phone: Phone Number

Patient Information:

Name: Patient Full Name

Date of Birth: DOB Patient ID: ID Number Address: Patient Address Phone: Phone Number

1. PROPOSED TREATMENT/PROCEDURE

Name of Treatment/Procedure: Treatment/Procedure Name

Description:

Detailed description of what the treatment or procedure involves, including any medications, devices, or techniques that will be used

Purpose:

The purpose of this treatment/procedure is to: Explain the medical reason and expected benefits

Healthcare Provider(s):

• Primary physician: Name and credentials
• Other providers: Names if applicable

2. RISKS AND COMPLICATIONS

Common Risks (occur in more than 5% of cases):

• Risk 1
• Risk 2
• Risk 3

Uncommon but Serious Risks:

• Risk 1
• Risk 2
• Risk 3

Rare Risks:

• Any rare but important risks

Additional Risks Specific to You:

Based on your medical condition and history:

• Specific risk 1
• Specific risk 2

Risk of Not Proceeding:

If this treatment is not performed:

• Consequence 1
• Consequence 2

3. BENEFITS AND EXPECTED OUTCOMES

Expected Benefits:

• Benefit 1
• Benefit 2
• Benefit 3

Success Rate:

Percentage or description of typical outcomes

Important Note:

No guarantee can be made regarding the results. Individual results may vary based on many factors including your overall health, adherence to treatment plan, and individual response.

4. ALTERNATIVES

Alternative Treatments Include:

Option 1: Alternative treatment

• Risks: Risks
• Benefits: Benefits
• Expected outcomes: Outcomes

Option 2: Alternative treatment

• Risks: Risks
• Benefits: Benefits
• Expected outcomes: Outcomes

Option 3: No treatment/Watchful waiting

• Risks: Risks
• Expected course: Natural progression

Why This Treatment is Recommended:

Explanation of why the proposed treatment is recommended over alternatives

5. PROCEDURE DETAILS

Before the Procedure:

• Preparation required: Fasting/Medication adjustments/Other
• Tests needed: Blood work/Imaging/Other
• Arrival time: Time
• Items to bring: ID/Insurance card/List of medications/Other

During the Procedure:

• Estimated duration: Time
• Anesthesia type: Local/Regional/General/Sedation/None
• What to expect: Description

After the Procedure:

• Recovery time in facility: Duration
• Discharge timing: Same day/Overnight/Other
• Transportation: Require driver/Can self-transport
• Activity restrictions: Duration and details

6. RECOVERY AND FOLLOW-UP

Recovery Timeline:

• Return to normal activities: Timeframe
• Return to work: Timeframe
• Full recovery expected: Timeframe

Post-Procedure Care:

• Wound care: Instructions
• Medications: Prescriptions and over-the-counter
• Activity restrictions: Details
• Diet modifications: If any

Follow-Up Appointments:

• First follow-up: Timeframe
• Additional visits: As needed

Warning Signs - Seek Immediate Care If:

• Warning sign 1
• Warning sign 2
• Warning sign 3
• Emergency contact number

7. ANESTHESIA INFORMATION (If Applicable)

Type of Anesthesia: Type

Anesthesia Risks:

• Common: Nausea, sore throat, drowsiness
• Uncommon: Allergic reaction, breathing difficulties
• Rare: Serious complications or death

Anesthesia Provider: Name and credentials

Pre-Anesthesia Instructions:

• NPO (nothing by mouth) after: Time
• Medication adjustments: Details
• Other instructions

8. PATIENT RESPONSIBILITIES

I Understand That I Must:

• Provide complete and accurate medical history
• Disclose all medications, supplements, and allergies
• Follow all pre-procedure instructions
• Arrange for transportation (if required)
• Follow post-procedure care instructions
• Attend follow-up appointments
• Report any complications or concerns promptly
• Ask questions if I don't understand something

I Have Disclosed:

• All medical conditions and previous surgeries
• All current medications and supplements
• All allergies (medication and other)
• Use of tobacco, alcohol, or recreational drugs
• Pregnancy or possibility of pregnancy (if applicable)

9. BLOOD TRANSFUSION (If Applicable)

Possibility of Blood Transfusion:

• Unlikely
• Possible
• Probable

Risks of Transfusion:

• Allergic reactions
• Infection (rare with modern screening)
• Transfusion reactions

I consent to blood transfusion if medically necessary:

• Yes
• No (I understand this may affect treatment options)

10. SPECIMENS AND TISSUE

Tissue Removal:

If tissue is removed, it may be:

• Examined for diagnostic purposes
• Stored for medical records
• Used for education/research (de-identified)
• Disposed per medical standards

I consent to the above uses:

• Yes
• No

11. PHOTOGRAPHY AND RECORDING

Medical Documentation:

Photographs, videos, or recordings may be taken for:

• Medical records
• Treatment planning
• Quality assurance

I consent to medical documentation:

• Yes
• No

Educational/Research Use:

De-identified images may be used for:

• Medical education
• Professional presentations
• Research publications

I consent to educational/research use:

• Yes
• No

12. STUDENTS AND TRAINEES

Teaching Institution:

• This is/is not a teaching facility
• Medical students, residents, or other trainees may participate under supervision

I consent to trainee participation:

• Yes
• No

13. UNFORESEEN CIRCUMSTANCES

During the Procedure:

If unforeseen conditions are discovered requiring additional or different treatment:

I authorize the physician to:

• Proceed with additional medically necessary treatment
• Wake me to discuss options (if possible)
• Contact designated decision-maker: Name/Phone

14. COSTS AND INSURANCE

Financial Responsibility:

• I understand I am responsible for all charges
• Insurance coverage: Insurance company
• Estimated out-of-pocket cost: Amount or "Contact billing"
• Payment arrangements: Details if applicable

I have been informed of estimated costs:

• Yes
• No

15. PATIENT RIGHTS

I Understand I Have the Right To:

• Ask questions and receive answers
• Seek a second opinion
• Refuse treatment
• Withdraw consent at any time before the procedure
• Review my medical records
• Have an advocate or interpreter present
• Make my own healthcare decisions (if competent)

Advance Directives:

• I have/have not executed advance directives
• If yes, copy provided to facility: Yes No

16. COMMUNICATION AND QUESTIONS

Opportunity to Ask Questions:

I have had the opportunity to ask questions about:

• The treatment/procedure
• Risks and benefits
• Alternatives
• Recovery and outcomes
• Any other concerns

My questions have been answered to my satisfaction:

• Yes
• No (explain): _______________

Provider Signature:

I have discussed the above with the patient/decision-maker and answered all questions.

Signature: _______________________

Name: Provider Name

Credentials: Credentials

Date: _______________________

Time: _______________________

17. SPECIAL CIRCUMSTANCES

Minor Patient:

If patient is under 18, parent/guardian consent required.

Incapacitated Patient:

If patient cannot consent, authorized decision-maker:

• Legal guardian
• Healthcare proxy
• Next of kin per state law

Decision-Maker: Name

Relationship: Relationship Authority: Legal basis

Language Assistance:

• Interpreter used: Language
• Interpreter name: Name

18. VOLUNTARY CONSENT

I Acknowledge:

• I have read this form (or it has been read to me)
• I understand the information provided
• I have had adequate time to consider my decision
• I have not been pressured or coerced
• I am consenting voluntarily
• I may withdraw consent before the procedure begins

19. CONTACT INFORMATION

Questions or Concerns:

Before the procedure: Phone/Email After hours: Phone Emergency: Phone or 911

20. AUTHORIZATION

By signing below, I confirm:

• I am the patient or authorized decision-maker
• I consent to the proposed treatment/procedure
• I understand the risks, benefits, and alternatives
• I authorize the healthcare provider to proceed

PATIENT/DECISION-MAKER SIGNATURE:

Signature: _______________________

Printed Name: Name Relationship to Patient: Self/Parent/Guardian/Healthcare Proxy/Other

Date: _______________________

Time: _______________________

WITNESS SIGNATURE (If Required):

Signature: _______________________

Printed Name: Name

Date: _______________________

Time: _______________________

INTERPRETER SIGNATURE (If Applicable):

I have accurately interpreted the contents of this form.

Signature: _______________________

Printed Name: Name Language: Language

Date: _______________________

PROVIDER COPY / PATIENT COPY / MEDICAL RECORD COPY