Medical Consent Form

A medical consent form is a common legal document used in the healthcare industry to obtain medical consent for a certain treatments or medical procedures. It includes information about the patient and provides details about the medical treatment or procedure being performed.

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What is Medical Consent? Guide to Medical Consent Medical Consent for Children What is Informed Refusal?

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What is Medical Consent?

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. Medical consent is generally given along with a medical waiver, that releases the medical provider from liability.

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.

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Guide to Medical Consent

Updated on February 28, 2021

Often, medical consent situations are expected, but in other cases, they arise in moments of a 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.

If the language of the medical consent form also releases the medical professional from liability, it becomes a medical liability waiver form.

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: