Can these instructions be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided you capture intent, consent, attribution, and retention. Confirm exceptions for specific transaction types and obtain consumer-facing disclosures when required.

Do I need HIPAA protections for delivery?

Yes. If instructions include protected health information, use HIPAA-compliant transmission and storage; enter into a BAA with the vendor to satisfy HIPAA requirements for handling PHI.

What if a patient cannot sign electronically?

Provide an alternative such as an in-person paper signature, caregiver signature, or assisted signing workflow. Document the accommodation and include an audit trail that records who assisted and why.

How long must signed instructions be retained?

Follow HIPAA retention (6 years per 45 CFR §164.530(j)) and any payer or state requirements. Retain the longest applicable period and ensure records remain accessible for audits and legal review.

Can I use remote notarization or witnesses?

Remote online notarization is permitted in many states with identity proofing and audio-video recording requirements; verify state rules for RON and witness counts before relying on a remote notarization process.

How do I attach signed forms to the EHR?

Export as a durable PDF with audit metadata and import into the chart using your EMR's document upload feature or automated integration. Ensure the stored copy preserves timestamps and signer attribution.

Electronic Signature
Templates
Healthcare
Healthcare Pre-Treatment Instructions

Healthcare Pre-Treatment Instructions

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE PRE-TREATMENT INSTRUCTIONS

Patient Name: Date of Birth: Gender:

Patient Information

Address Primary Phone Email Emergency Contact (Name, Relationship, Phone)

Insurance Information

Insurance Provider Policy / ID Number Group Number Policyholder / Subscriber

Medical History

Current Medications Allergies Prior Surgeries / Hospitalizations Chronic Conditions

Procedure Information

Procedure / Treatment: Treating Clinician:

Scheduled Date: Estimated Duration:

Planned Anesthesia / Sedation (check all that apply)

Local anesthesia Regional anesthesia General anesthesia Conscious sedation None / Topical only

Pre-Treatment Instructions — Patient Responsibilities

The following instructions are required to reduce risk and ensure safe administration of the planned treatment. Please read each item and check to confirm you understand and will comply.

I will fast as instructed (no food or drink for the period specified by the clinic). If hours differ for solids or liquids, follow clinician instructions. If fasting instructions are unclear, contact the clinic prior to the procedure.

I will follow medication adjustment instructions, including temporary discontinuation of anticoagulants, antiplatelet agents, or other specified drugs as directed by the treating clinician.

If you take blood thinners or anticoagulants, list medication name(s) and last dose

I will arrange reliable transportation home if sedation, anesthesia, or other medications are used. I will not drive, operate heavy machinery, or legally engage in activities requiring full alertness for the period specified by the clinician following the procedure.

I will wear comfortable clothing and remove jewelry, contact lenses, and dentures if instructed. I understand the clinic is not responsible for lost personal items.

Female patients of childbearing potential confirm they are not pregnant or have informed the clinic if pregnancy is possible. I will notify the clinic immediately if pregnancy is suspected.

I will notify the clinic if I develop any new illness, fever, cough, cold, or infection before the scheduled procedure.

Other patient-specific instructions provided by clinician (describe)

Risks, Benefits & Right to Withdraw

The benefits of proceeding with the scheduled treatment include therapeutic effect, symptom relief, or diagnostic information as discussed with the clinician. All medical procedures and medications involve risks, including but not limited to infection, bleeding, adverse reaction to medications or anesthesia, and unforeseen complications. The clinician has explained common and material risks relevant to the planned procedure. The patient has the right to ask questions and to withdraw consent at any time prior to the start of the procedure.

By signing below the patient acknowledges receipt of the pre-treatment instructions, understands the potential risks and benefits, and agrees to follow the listed instructions. Noncompliance with pre-treatment instructions may lead to postponement or cancellation of the procedure for safety reasons.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been informed of the facility's privacy practices regarding the use and disclosure of my protected health information. I understand that information necessary for treatment, payment, and healthcare operations may be used or disclosed in accordance with applicable privacy laws and facility policy.

I acknowledge and consent to release medical information as necessary for treatment and billing purposes and as otherwise required or permitted by law.

Authorization and Expiration

This authorization to proceed and the acknowledgments set forth above shall remain valid for the scheduled procedure date and any rescheduled date occurring within the specified period below.

Authorization valid until

WARNING: Failure to follow these pre-treatment instructions may increase the risk of complications. If you do not understand any instruction, you must notify the clinic before the procedure.

Patient Name:

Signature:

Date:

If signing as guardian or authorized representative, state relationship

By signing above I certify that I have authority to sign on behalf of the patient (if applicable), that the information provided in this Pre-Treatment Instructions form is true and complete to the best of my knowledge, and that I understand the obligations and warnings contained herein.

What Healthcare Pre-Treatment Instructions Are

Healthcare Pre-Treatment Instructions are written or electronic directions provided to patients before diagnostic tests, procedures, imaging, or minor surgical interventions. They explain preparation steps such as fasting, medication adjustments, arrival time, and required documentation; identify possible risks and when to seek help; and capture patient acknowledgment or consent. In many clinics these instructions are paired with a checklist or signature field so the provider documents patient understanding. Electronic delivery and signatures are generally permitted under federal ESIGN law (15 U.S.C. ch. 96) and state UETA statutes, subject to healthcare-specific requirements such as HIPAA.

Why Clear Pre-Treatment Instructions Matter

Clear instructions reduce day-of cancellations and clinical risk, improve patient safety, and create a documented record of patient acknowledgement that supports billing, authorization, and quality review while helping meet regulatory obligations such as HIPAA.

Who Prepares and Uses These Instructions

Typical users include clinical staff who create instructions, administrative staff who distribute them, and patients or guardians who follow and acknowledge them.

Patients and guardians who must acknowledge or follow preparation steps before a procedure.
Clinical staff (nurses, medical assistants) who confirm eligibility and provide clarifications.
Administrative or billing staff who track signed acknowledgements and attach records to the chart.

The same document may be reviewed by clinical leadership, compliance teams, and billing staff to ensure readiness and documentation for procedures.

Step-by-Step: Completing Pre-Treatment Instructions

Follow these steps to ensure the patient receives, understands, and acknowledges the instructions before treatment.

01

Prepare the document: Customize instructions for the procedure and patient needs.
02

Deliver securely: Send by secure portal, SMS-secured link, or printed copy.
03

Confirm understanding: Review checklist with patient and answer questions.
04

Capture acknowledgement: Obtain signature, timestamp, and store in the chart.

Configuring an Electronic Pre-Treatment Workflow

Set up delivery, authentication, reminders, and storage to match your clinic's compliance and operational needs.

Field	Configuration
Email delivery	Secure link with SSL; optional access code
Authentication	Email plus SMS code or organization SSO
Auto-reminders	Send 48h and 24h reminders before appointment
Archive location	Store in HIPAA-compliant EMR or secure cloud

Technical Requirements for Digital Distribution

Confirm your platform supports secure delivery, audit trails, and formats compatible with your EHR and archive policies.

File formats: PDF or DOCX for EMR compatibility
Integrations: Microsoft 365, Google Workspace, Box supported
Security: TLS 1.2/1.3; AES-256 at rest

Where to Send and Store Completed Instructions

Route signed instructions to clinical systems, the patient record, and any applicable administrative queues to support care continuity.

Send to patient: Deliver signed copy to patient's secure inbox
Attach to chart: Import PDF into the EMR as encounter documentation
Notify staff: Alert clinical team the patient is prepared
Retain for audit: Store an immutable copy with audit metadata

Typical Timing and Deadlines Patients Must Follow

Instructions often include explicit time windows tied to safety, anesthesia, and lab requirements; communicate these deadlines clearly.

NPO (Fasting):

Commonly 6–8 hours before anesthesia or sedation

Medication adjustments:

Stop or adjust 24–72 hours per clinician guidance

Pre-procedure tests:

Complete labs or imaging 24–72 hours prior

Arrival time:

Typically 45–90 minutes before scheduled start

Signed consent:

Must be completed before the procedure begins

Common Preparation Mistakes to Avoid

Incomplete medication lists or withheld OTC drugs that increase peri-procedural risk and cause delays.
Failure to follow fasting instructions leading to procedure cancellation or rescheduling on the day of service.
Unsigned or undated acknowledgements that create billing issues and missing consent documentation during reviews.
Poor delivery method (unsecured email or no reminders) resulting in low completion rates and last-minute patient questions.

Risks and Consequences of Incorrect Instructions

Procedure cancellation: Delays and rescheduling

Billing denial: Payer may deny claims

Clinical harm: Increased medical risk

Liability exposure: Potential malpractice claims

HIPAA violation: Regulatory penalties possible

Loss of trust: Patient dissatisfaction and complaints

Essential Data Elements to Collect and Protect

Protected Health Info: PHI per HIPAA: limit collection to necessary items

Patient ID: Medical record number and DOB for matching

Procedure Code: CPT or short descriptor for correct prep

Allergies: Active allergies and reactions

Medication List: Prescription and OTC medications listed

Emergency Contact: Name and phone for post-procedure issues

eSignature Provider Comparison for Healthcare Pre-Treatment Workflows

Key pricing and compliance features for eSignature vendors. signNow is listed first for comparison; verify vendor plans and enterprise terms directly with providers.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Common Questions About Pre-Treatment Instructions

Answers to frequent operational and legal questions when using electronic pre-treatment instruction forms.

Need help? Contact support

Can these instructions be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided you capture intent, consent, attribution, and retention. Confirm exceptions for specific transaction types and obtain consumer-facing disclosures when required.
Do I need HIPAA protections for delivery?
Yes. If instructions include protected health information, use HIPAA-compliant transmission and storage; enter into a BAA with the vendor to satisfy HIPAA requirements for handling PHI.
What if a patient cannot sign electronically?
Provide an alternative such as an in-person paper signature, caregiver signature, or assisted signing workflow. Document the accommodation and include an audit trail that records who assisted and why.
How long must signed instructions be retained?
Follow HIPAA retention (6 years per 45 CFR §164.530(j)) and any payer or state requirements. Retain the longest applicable period and ensure records remain accessible for audits and legal review.
Can I use remote notarization or witnesses?
Remote online notarization is permitted in many states with identity proofing and audio-video recording requirements; verify state rules for RON and witness counts before relying on a remote notarization process.
How do I attach signed forms to the EHR?
Export as a durable PDF with audit metadata and import into the chart using your EMR's document upload feature or automated integration. Ensure the stored copy preserves timestamps and signer attribution.

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