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A medical consent form is used to obtain medical consent for certain treatment or medical procedure.

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What is Medical Consent? 

A medical consent form is a common form used in the healthcare industry to obtain medical consent for a certain treatment or medical procedure. It includes information about the patient and provides details about the medical treatment or procedure being performed. Medical consent is typically granted by the patient receiving the treatment, as long as they are of consenting age. For children, consent is generally given by a parent or guardian. For those who cannot speak for themselves, such as someone who is elderly, has a disability, or presents a special need, consent is generally given by a spouse or other family member. A medical consent form is generally complete and consent is officially granted when the person giving consent signs the form. A copy is generally given to both parties.

Although specific details vary by state, medical consent means that a physician or other medical care providers must inform a patient of any and all potential benefits, risks, and alternatives involved in a medical procedure. In other words, patients have the right to make an informed decision about their medical care based on all of the available medical information.

What is informed consent? 

Informed consent is required whenever a patient requires medical treatment or care that puts them at any risk of injury. Consent is not required for simple diagnostic tests or other procedures where a patient’s participation implies consent.

Informed consent recognizes a patient’s right to be informed about a procedure, treatment, surgery, or other medical procedure before deciding whether or not to proceed with the procedure. Informed consent is designed to protect patients, who have the right to refuse any treatment they do not desire.

For doctors, as long as a patient is mentally capable of making informed, rational medical decisions regarding their healthcare, medical treatment cannot begin unless informed consent is granted. If the patient is a minor, has a serious mental disability or cannot give consent, the patient’s parent, legal guardian, or court-appointed executor must grant consent.

Keep in mind that these medical and informed consents are used interchangeably.

Guide to Medical Consent

By FormSwift Editorial Team
May 15, 2018

Often, medical consent situations are expected, but in other cases, they arise in moments of medical emergency. This guide is designed to provide you with all of the information you need to manage any medical consent scenario, anticipated or unexpected.

What function Should a Medical Consent Form Serve?

A medical consent form must perform three functions:

1.) Summarize the nature and purpose of the procedure.

This can be brief and should stand out on the page. Consider making it bold and putting a nice tidy box around it. For example:

Knee replacement is a surgical procedure to relieve disability or pain and improve/sustain mobility of the knee. It involves partial or total replacement of damaged and/or diseased weight-bearing parts in the knee-joint with plastic and/or metal components.

2.) Provide an overview of risks and alternatives, and state that all risks, as well as any possible alternatives, have been explained to the patient/caregiver.

This section must summarize risks particular to the procedure and to the type of process in general. For example, a consent form (also known as an authorization form) for knee surgery should include something like this:

I understand all possible risks of knee surgery which include damages incurred to the leg and surrounding area.

As well as something like this:

I understand all possible risks of invasive procedures include infection, bleeding, paralysis, stroke, permanent injury, and death.

A good way to handle medical alternatives is to include a "fill-in clause," such as -

Possible alternatives to knee surgery include _________.

This section should also include explicit statements that the purpose of the surgery, as well as all risks, have been explained to the patient/caregiver. For example:

The purpose and nature of this procedure have been explained to me. I have also been informed of all medically significant risks of the aforementioned procedure. I am aware that no guarantee can be made regarding the outcome of the aforementioned procedure. All reasonable alternative treatments, including consequences and medically significant risks, have also been explained to me. I have also been made aware of the risks and consequences of no treatment.

If you want to be thorough (which you should), you can throw in a short quiz section at the end. Questions can look something like the following:

The benefits of knee replacement surgery include _______.

One of the risks of knee replacement surgery is _________.

This will ensure that the patient/guardian has a complete understanding.

3.) Function as a Waiver.

In this last section, the patient/guardian must provide his or her legal consent. The patient's full legal name must be provided, along with the name of the procedure and the full legal name of the physician and healthcare institution.

When Do You Need Medical Consent? 

Informed consent is required whenever a patient requires medical treatment or care that puts them at any risk of injury. Consent is not required for simple diagnostic tests, x-rays or other procedures that are not life-threatening where a patient’s participation implies consent.

Scenarios Where Medical Consent Requirements Vary

There are some situations where the requirements for medical consent vary. In others, they do not apply at all. Here’s a rundown of each:

  • Medical consent is not required in an emergency
    • If a physician determines a patient is experiencing a medical emergency, they can treat the person regardless of medical consent.
    • For example, if a person is unconscious and in danger of death or serious injury, if care is not immediately administered, medical consent is not required. This may include a blood transfusion, surgery, or other life-saving medical treatments.
    • If the medical team administering treatment knows the patient has an advance directive refusing care in a certain situation, they will make a decision based on knowledge of the wishes in that document
  • For minors: the requirements for medical consent are even lower. In many cases, a doctor can administer care without consent, even if the patient is not experiencing an emergency.
    • The state can also override parents under the “parens patriae” doctrine, which enables the state to act as a parent and grant consent for medical care.
    • Child Protective Services (CPS) may also be called in to give consent.

What is the Process of Informed Consent? 

  • The patient is informed about the possible risks and benefits of the treatment.
  • The patient is told about risks and benefits of other options, including no treatment.
  • The patient has a chance to ask the doctor questions. The doctor must answer all questions.
  • The patient has time to discuss the plan with family or advisors (if needed).
  • The patient considers all provided information and makes a decision in their best interest.
  • The patient shares their decision with their doctor.
  • The patient signs a consent form, if necessary.
    • Note: Once you sign a consent form, you have legally agreed to the plan or procedure on the authorization form, unless you revoke the consent before treatment is given.

What is Informed Refusal? 

After the back and forth between a patient and their doctor is completed (outlined above), a patient may decline the physician’s recommendation and acknowledge the risks of doing so. This action is called informed refusal.

Malpractice and Medical Consent

Here’s a simple way to consider whether or not malpractice may have occurred in your medical care:

The standard for a physician in a malpractice suit is how other physicians in their specialty would have responded in a similar situation. If other physicians would have acted similarly, then no malpractice exists. If, however, other physicians would have acted differently, malpractice may have occurred.

For minors, whether a lawsuit is filed and how malpractice lawsuits are handled depends in part on the child’s response to treatment--i.e. if a minor responds positively to treatment, it is hard to find evidence of malpractice.

In Conclusion

We hope this guide provides you with important information about the medical consent process and legal standards informing it, as well as your rights as a patient or parent or guardian of a patient. Whether medical situations arise requiring consent are expected or unexpected, we believe this guide provides you with the information you need to navigate the medical consent process in an informed manner that guides you through planning ahead for any unforeseen medical consent emergency.

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