Templates Health & Wellness Medical Health Consent Form Template

Health Consent Form Template

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Patient Information

Full Name

Emergency Contact

Treatment Information

  • Description of Procedure/Treatment: This section details the specific medical procedure or treatment for which consent is being sought. 
  • Potential Risks and Complications: List of possible risks associated with the procedure, such as "Risk of infection, bleeding, or adverse reaction to anesthesia."
  • Expected Benefits: Description of the anticipated benefits of the procedure, such as "Relief from pain and prevention of further health complications related to appendicitis."
  • Alternatives: Information on alternative treatments or procedures, including any non-action, with their respective risks and benefits.
Consent Statement
Consent Statement (copy)
Consent Statement (copy) (copy)
Clear Signature

The Health Consent Form Template by WPForms is designed for all types of clinics, hospitals, and healthcare professionals who are looking for a simple way to acquire consent from patients for specific treatments.

How Does the Health Consent Form Template Work?

The Health Consent Form Template requires the WPForms Pro License and the Signature Addon to collect patient information and acquire their consent via a digital signature for any recommended treatments. Fields include:

  • Patient Information:
    • Full Name: Records the patient’s name for accurate identification
    • Gender: Notes the patient’s gender, critical for personalizing care.
    • Date of Birth: Essential for verifying the patient’s age for medical records
    • Email Address: A means to communicate important information or updates.
    • Phone Number: Direct contact information for any immediate communication.
  • Emergency Contact:
    • Full Name: Information of someone to contact in case of an emergency.
    • Relationship to the Patient: Clarifies the emergency contact’s relationship.
    • Email Address: For non-urgent communications or updates.
    • Phone Number: A secondary means of urgent communication.
  • Authorization:
    • Treatment Information: Detailed description of the treatment.
    • Consent: A series of statements the patient or guardian must agree to.
    • Signature and Date: A field for the digital signature of the patient.

Sign up with WPForms today and access the Health Consent Form Template. It is ideal for medical clinics, hospitals, and healthcare practitioners requiring a solution to managing patient consent efficiently and securely.