"Medical Consent Form"

What Is a Medical Consent Form?

A Medical Consent Form is a written document that grants an individual or organization the authority to perform medical services. This form is required by medical providers for any procedure that has even minimal harm to the patient's health. It explains the risks of the procedure to the patient and their representatives and confirms the patient is aware of the treatment and operation - this way, physicians comply with legal requirements and conduct a proper medical practice. Additionally, informed consent means the doctor and the patient now share authority on the patient's health and are equally responsible for the outcome of the proposed procedure.

Alternate Names:

  • Minor Medical Consent Form;
  • Child Medical Consent Form.

You can download a Medical Consent Form template via the link below. While we offer a generic form, you can customize it to your liking and later use it before you treat both adults and minors.

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How to Write a Medical Consent Form?

Follow these steps to prepare a Medical Consent Form:

  1. Name the parties - the person who agrees to a medical procedure or treatment and the medical facility . If you know who will perform surgery or, for instance, the patient has decided they want to be operated on by a specific physician, you need to state their name as well. In case the patient is a child, a minor Medical Consent Form must contain the name of the person who authorized the treatment.
  2. Describe the nature of consent - for example, the patient will provide a blood sample for laboratory tests . Indicate the date of the procedure and list the recommendations given by the doctor to their patient.
  3. Include information about the patient's diagnosis, benefits of the treatment, and steps that have already been taken to treat the individual . Of course, if the consent is given for the first medical evaluation of the patient and the physician knows there will not be any harm to the patient's health, you can skip this part - instead, confirm the patient's agreement to be examined by a specific doctor ...
  4. Disclose any risks, side effects, and alternative choices to the procedure or operation in question . If the patient takes medication and has any allergies or underlying conditions, they must inform the physician prior to the procedure - any restrictions or warnings have to be put in writing.
  5. Include the patient's contact information - in case anything goes wrong, it will be easier to find people who must be notified about the patient's condition . Note that it is necessary to authorize the medical provider to disclose sensitive information about the patient's health to people named in the form as well as add their contact details.
  6. Sign the document . The patient's signature demonstrates their intention to accept clinical evaluation and treatment and understanding of all the treatment options offered by the healthcare provider. While a Medical Consent Form for adults only requires the signature of the individual who will be treated, a child Medical Consent Form must be reviewed and signed by their parent or legal guardian.

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Medical Consent Form
I, ____________________, am a [​
P arent/Legal Guardian​
] of ____________________,
born on ____________________, do hereby consent to the following medical care while
said individual is under the care of ____________________ of ____________________,
City of ____________________, State of ____________________:
❏ X-ray examination;
❏ Anesthetic;
❏ Medical, surgical or dental diagnosis or treatment;
❏ Hospital care;
❏ Other: ____________________________________________________________.
____________________
____________________
____________________
Hospital Insurance
Policy Number
Insurance Company
(if applicable)
(if applicable)
(if applicable)
The undersigned shall be liable and agrees to pay all costs and expenses incurred in
connection with such medical and dental services rendered. Should it be necessary for the
undersigned to return home, the undersigned shall assume all transportation costs.
This authorization is effective from ___________________, to ____________________.
_________________________________
_________________________________
Name of Parent/Legal Guardian
Witness Name
_________________________________
_________________________________
Signature of Parent/Legal Guardian
Witness Signature
_________________________________
_________________________________
Date
Date
© ​
T EMPLATEROLLER.COM
Medical Consent Form
I, ____________________, am a [​
P arent/Legal Guardian​
] of ____________________,
born on ____________________, do hereby consent to the following medical care while
said individual is under the care of ____________________ of ____________________,
City of ____________________, State of ____________________:
❏ X-ray examination;
❏ Anesthetic;
❏ Medical, surgical or dental diagnosis or treatment;
❏ Hospital care;
❏ Other: ____________________________________________________________.
____________________
____________________
____________________
Hospital Insurance
Policy Number
Insurance Company
(if applicable)
(if applicable)
(if applicable)
The undersigned shall be liable and agrees to pay all costs and expenses incurred in
connection with such medical and dental services rendered. Should it be necessary for the
undersigned to return home, the undersigned shall assume all transportation costs.
This authorization is effective from ___________________, to ____________________.
_________________________________
_________________________________
Name of Parent/Legal Guardian
Witness Name
_________________________________
_________________________________
Signature of Parent/Legal Guardian
Witness Signature
_________________________________
_________________________________
Date
Date
© ​
T EMPLATEROLLER.COM