Healthcare ICF Template

HEALTHCARE INFORMED CONSENT FORM (ICF)

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical History

Procedure / Treatment Information

Proposed Procedure/Treatment:    Performing Clinician:

Scheduled Date:

Purpose: The purpose of the proposed procedure/treatment is to provide medical benefit as described above. The expected benefit, if successful, is:

Risks, Complications and Alternatives

Material Risks: I understand that the procedure may involve risks, which may include but are not limited to:

• Infection, bleeding, need for additional procedures or transfusion;
• Damage to adjacent structures or organs;
• Anesthesia-related complications including allergic reaction or respiratory problems;
• Failure to achieve desired outcome, chronic pain, scarring, or functional impairment;
• Rare but serious risks including permanent disability or death.

Alternatives: Reasonable alternatives to the proposed procedure have been explained, including no treatment and nonsurgical options. Alternatives discussed:

I acknowledge that I have had the opportunity to ask questions about the risks, benefits and alternatives and that my questions have been answered to my satisfaction. Initials:

Anesthesia / Sedation

The use of anesthesia or sedation has been explained, including attendant risks and the need for monitoring. Type planned:

Consent for Photography / Recording

I consent to clinical photography, video or audio recording for documentation and treatment purposes: Yes No

HIPAA & Authorization for Release of Protected Health Information

I authorize the disclosure of my protected health information to the individuals or entities identified below for purposes related to treatment, billing and care coordination.

Purpose of disclosure:

This authorization will expire on:

I understand that I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization.

Patient Rights and Voluntary Consent

I acknowledge that the clinician has explained the nature and purpose of the procedure, the expected benefits, the material risks, and the reasonable alternatives including no treatment. I understand that I may withdraw my consent at any time prior to the procedure without affecting my future care.

I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction. I confirm that I understand the information provided and consent to the procedure described above.

Certification

By signing below I certify that I am the patient or the patient representative authorized to make healthcare decisions on behalf of the patient. I certify that the information provided on this form is true and complete to the best of my knowledge.

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