Consent form template for clinics

A free, printable informed consent form for a procedure or treatment. Print it, or save it as a PDF, and fill it in with the patient.

What an informed consent form should include

  • The patient’s name, age and record number, and the date and time.
  • The name of the procedure or treatment, and the doctor who will perform it.
  • That the condition, the procedure, its benefits, its risks and the alternatives were explained in a language the patient understands.
  • That the patient could ask questions, and that no result was guaranteed.
  • That the patient may withdraw consent before the procedure begins.
  • Signatures, with date and time, of the patient or guardian, a witness and the doctor.

The format

[Clinic / hospital name, address and phone]

INFORMED CONSENT FOR PROCEDURE / TREATMENT

Patient name:  Age / Sex:  

Record No.:  Date and time:  

Procedure / treatment:  

Doctor: Dr.  

I, the undersigned, confirm that:

  1. The doctor has explained my condition and the proposed procedure to me, in a language I understand.
  2. I have been told the expected benefits, the possible risks and complications, and the alternatives, including not having the procedure.
  3. I understand that anaesthesia or sedation may be needed, and its risks have been explained to me.
  4. I have had the chance to ask questions, and they have been answered to my satisfaction.
  5. I understand that no guarantee has been given to me about the result.
  6. I understand that I may withdraw this consent at any time before the procedure begins.
  7. I consent to the procedure named above, and to any further procedure the doctor finds necessary during it in my interest.

Patient (signature or thumb impression)

Name:  

Date and time:  

Guardian, if the patient cannot consent

Name and relationship:  

Date and time:  

Witness

Name:  

Date and time:  

Doctor

Name and Registration No.:  

Date and time:  

A general format for reference. Adapt it to your practice and to the laws and medical council rules that apply to you. It is not legal advice.

Skip the blanks

checkup.care sends consent forms to the patient’s phone to read and sign, and files the signed copy in their record. Your own templates, with the patient’s details filled in.

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