Customizable Consent To Treat Form Template

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PURPOSE: The purpose of the "Consent to Treat Form" is to gain the patient's consent in order to participate in treatment appointments.

RECORDS: Communications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

HEALTH INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the appointment and treatment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to appointments and treatment.

Patient's Name

First

Last

Date of Birth

Parent/Guardian Name

First

Last

Layout

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact Number

Consent

Please check the box to agree.

I understand that all the laws that are protecting my privacy of medical history or information are also applied to these practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals for my treatment and diagnosis.

Signature

Date

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Are you in the medical field and want to collect consent forms straight from your website? If so, then you need the Consent To Treat Form Template from WPForms.

This template is a great starting point to get all your consent forms ready for use with potential clients and patients.

Using the Consent To Treat Form Template

The purpose of a Consent to Treat Form is to obtain informed consent from a patient or their legal guardian before initiating medical treatment. By signing, the patient or legal guardian acknowledges their understanding and gives permission for the healthcare provider to proceed with treatment.

So, it’s important that the consent form includes all of the fields and questions needed for your patients to offer their informed consent.

On our Consent To Treat Form Template, the user is first met with a handful of explanations describing the details of use for this form. This is a standard part of most medical consent forms and is something that you can keep, edit, or delete as you see fit.

The form user then enters the patient information. This section collects the patient’s name, date of birth, parent or guardian’s name (if applicable), email, phone number, and address. The form also collects an emergency contact phone number.

Next, the user consents to the use of the information on this form by checking a box. The verbiage used on this part of the form is another standard aspect of a consent form. But, once again, you’re free to edit the language here however you’d like.

Finally, the user enters their signature and the date of their submission.

Get started with WPForms today to create and customize your own Consent To Treat Form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.

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You can select any template to view the demo and try it out. If it works for you, you can import it and publish it in minutes. Each WPForms template is fully customizable too. Our drag and drop form builder makes it easy to adapt any template to fits your business’ needs. When you use our form templates, you can easily: