Healthcare Patient Consent Page

Healthcare Patient Consent Page

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical History

Procedure / Treatment

Procedure / Service to be performed:

Scheduled Date:    Performing Provider / Facility:

Risks, Benefits, and Alternatives

I acknowledge that the provider has explained the nature and purpose of the proposed treatment or procedure, the anticipated benefits, the material risks (which may include but are not limited to infection, bleeding, scarring, anesthesia complications, nerve injury, failure to achieve desired outcome, and the need for additional procedures), and reasonable alternatives including the option of no treatment. I understand that not all risks can be listed and that complications may occur.

By checking the box below I confirm that the risks, benefits, and alternatives have been discussed with me in terms I understand.
I acknowledge that these have been explained and I understand them.

Specific Consents

Anesthesia: I consent to administration of local/regional/general anesthesia as necessary.

Blood Transfusion: I consent to blood or blood product transfusion if deemed medically necessary.    I refuse blood transfusion (if checked, discuss alternatives with provider).

Photography / Recording: I consent to clinical photography or video recording for treatment and medical record purposes. (Any use for teaching or publication will be without identifying information unless additional authorization is obtained.)

Research / Experimental Treatment: I consent to participate in treatment-related research or experimental procedures only if a separate consent has been provided and explained.

Authorization for Use and Disclosure of Health Information (HIPAA)

I authorize the release of my medical information, including records and images, to other health care providers, insurers, and as required for the purposes of treatment, payment, and health care operations. I understand that information disclosed pursuant to this authorization may include sensitive information such as mental health, substance use treatment, communicable disease, and HIV status where applicable. I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

I authorize the release of health information as described above.

Patient Rights and Acknowledgment

I understand that I have the right to ask questions and to have those questions answered before consenting to treatment. I have had an opportunity to discuss alternative treatments and expected outcomes. I understand that no guarantee has been made to me as to the results of the proposed procedure or treatment.

I understand I may withdraw this consent at any time prior to the start of treatment by informing the provider in writing, but withdrawal will not affect actions already taken based on this consent.

Certification and Signature

By signing below I certify that I am the patient or legally authorized to consent on behalf of the patient. I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have read and understand the foregoing and authorize the treatment and disclosures described above.

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