When you enter the hospital, you usually fill out forms. Many people don’t read the paperwork, but you’ll find the consent to treatment form among these sheets. If you are a medical service provider, you need patients to sign consent forms before you can treat them. As a patient, you most likely need to agree to be treated unless you’re dying or incapable of giving consent due to unconsciousness, but what are consent to treatment forms? How do they work? Do they have essential components, or are they all different? We’ll teach you everything you need to understand about creating or signing consent to treatment forms and explain other vital details everyone should know. Our professionally designed templates offer an easy-to-customize, refill and reuse form that anyone can work with and understand.
What Is a Consent to Treatment Form?
A consent to treatment form is a legal document patients sign for medical care practitioners. These forms allow doctors and other medical professionals to administer treatment. Signing the consent will enable you to accept some or all of the proposed treatment and protects the business from false claims that they practiced medicine on you without your agreement.
Essential Elements of a Consent to Treatment Form
Most consent to treatment forms cover about two pages to get all the pertinent information. We’ve given the two pages separately for this outline, but yours could be shorter or longer based on the patient’s needs and treatment plan.
Page 1
- A clear title stating that this is a consent to treatment form and page indicator if this document is more than one page long, as they often are.
- Hospital identification information
- Patient Name, surname UMRN, DOB, sex (if applicable), and address
- A brief statement that says the form is to be completed giving due consideration to the patient’s rights, health treatment code, or other applicable policy or law in your area.
- Doctor’s Declaration- This section is completed by the doctor or other medical professional who obtains consent. This should be a short list of steps the doctor took to ensure the patient was well informed, such as explaining the procedure and answering any questions.
- Treatment section- Briefly name the procedure, treatment, or investigation the patient plans to undergo.
- Anesthesia/Sedation disclosures- A check box can indicate these as well to show if the patient will receive local or general anesthesia or other sedatives during this treatment.
- Risk Disclosure- List any patient-specific or overall risks discussed with the patient
- Signature of Medical Professional- The doctor or other medical personnel who obtains consent should sign and date here. Please note that it is essential to include a second section if the person obtaining consent is not the same as the one providing treatment. In this case, both or all the medical professionals must sign to show they are involved in the treatments.
Page 2
- A clear title stating that this is a consent to treatment form and page indicator if this document is more than one page long, as they often are.
- Hospital identification information
- Patient Name, surname UMRN, DOB, sex (if applicable), and address
- Patient declaration- This is a checklist of items the patient must do, hear or understand before they sign their consent. For example, they should check a box if the doctor answered their questions, another to show they are aware of the risks, and so forth. Also in this section are the consent items like ‘I consent to undergo the treatments as outlined in this form’ and ‘I consent to a blood transfusion if necessary.’
- Name, date, and signature lines belong at the bottom of the patient declaration. Leave a line for parental consent in the case of minors.
- Interpreter declaration- This isn’t always needed, but it should be present on the form. Here you put information about the language spoken (or signed if the patient is deaf/hard of hearing), whether services were needed, a statement showing the interpreter provided the best possible translation, and lines for their name, signature, and date.
- Confirmation- If the patient is admitted to the hospital on a different day from the initial consultation, an additional line stating that they still agree to the treatment is necessary. Like other signature lines, this should include their name, signature, and date of admission for the procedure.
What to Ask your Doctor or Surgeon Before Giving the Consent
Asking questions is a normal part of the process before giving medical consent. However, it helps to know what you should ask. We’ve included a short list of some of the most important questions every patient should address before signing a consent form.
- What would happen if you refused treatment for this problem? Some treatments are more optional than others.
- Are there other treatment options? You may be able to make lifestyle changes in some cases rather than taking medication, though it depends on your situation and why you are seeking treatment.
- Is the procedure invasive? There is a difference between taking a pill or getting a cast and needing surgery. You deserve to understand what that means.
- Will you be under any form of anesthesia, and what are the risks? Anesthesia has inherent risks; some people are more susceptible, at risk of side effects, or less reactive.
- What is the success rate of this type of procedure, and is there anything you can do before, during, or after to increase the likelihood of a positive outcome?
- Do you, in particular, have additional risk factors for this specific treatment? Some risk factors include other medical conditions, medications, and age.
- What are the risks and potential complications, and how common are these? You cannot avoid all the risks, but knowing what to expect or look out for can help you heal better.
- Are there side effects you need to know about or seek treatment for if they occur? Some side effects are typical and expected, and others might be a significant concern.
- What is the name of the procedure, and what does it entail? Get the details on what will happen.
- What are the expected outcome and benefits of undergoing this treatment? Is this a cure or symptom mitigation?
- Will you need to stay at the hospital for any amount of time after treatment? If you need an overnight bag or have to wait a few hours, it’s best to be prepared.
- Do you need to arrange a ride, or can you drive yourself home afterward?
- What is the recovery time?
- Will you recover completely?
- Are there any lasting effects you should know about?
Obtaining Informed Consent
There is a process for obtaining informed consent. As a physician or other medical professional, it is essential that you work to inform the patient about the whole treatment and their options without coercing them to sign. While the steps don’t necessarily have to happen in the order displayed below, the steps are outlined here.
- Explain the treatment, so the patient understands what will happen if they agree.
- Answer questions the patient has about the process and other aspects of treatment.
- Ensure that the patient understands their part in consent and how it works.
- If possible or necessary, discuss alternative treatment options. These won’t always be available, but the patient must know if they are.
- Discuss any risks, side effects, or other potential downsides.
- Discuss the benefits of the treatment.
- Have a conversation about any concerns they may have.
- Request the patient to sign the form.
If You Have Doubts About Giving the Consent
It is normal to have misgivings about medical treatment and what you’re agreeing to. Fortunately, you do not need to accept whatever you’re told blindly. If you have doubts about giving consent for treatment, you’ll find information here about the most common reasons and what you should do about them.
- Are your doubts related to a language barrier? If so, it is crucial to understand that you have the right to an interpreter.
- Are your doubts due to a lack of understanding of the process or its risks? You can make another appointment to discuss your concerns. Some doctors even offer teleconferences or online consultations to aid this process.
- Are your concerns a result of complex medical terminology? Have the medical professional explain things in simpler terms. There’s nothing wrong with you for not knowing everything a doctor spends seven years in school to learn.
- Are your doubts about the doctor or other professional? You can ask for a referral to another doctor or seek out a second opinion.
- Are you concerned that other health issues could complicate the treatment? Always discuss your complete medical history, including current treatments and medications. Make sure you also mention any supplements or over-the-counter medications you use.
ProTip: Many people are generally nervous, have anxiety, or have some trauma to work through related to medical care. If your unease is related to something like this, you should probably still consent to the treatment. However, it is okay to ask for a friend or family member to be present in some cases, like for a routine checkup. You can even authorize that person to answer for you if you need to dissociate or distract yourself to get through the treatment. Discuss this with your doctor, and seek out medical professionals who understand and are willing to work with you.
Important Tips About Giving Medical Consent
Giving medical consent is not something you should do blindly, and you do not have to agree to everything. Here are a few important tips about giving medical consent that may help you better understand and have a more positive experience.
- Consent is not permanent. You can change your mind and agree to more or remove your consent at any time.
- Listen to your doctor. They should give you aftercare instructions. Whether and how well you follow these can significantly impact how you heal and the success of the treatment.
- You are never obligated to give consent. It is always optional, and the doctors should not pressure you to sign.
- If you completely refuse treatment, medical professionals cannot help you.
- Medical professionals should not force you or coerce you into treatment. If you’re uncomfortable with the medical professional’s behavior, you can refuse and seek another care facility. In extreme cases, you can (and should) report the behavior to the licensing board if you believe you’ve been mistreated. However, this cannot be used to complain about the gender, race, disability, or other protected status of your medical staff simply because you do not like or agree with it.
FAQs
There are numerous questions related to consent to treatment forms. Here, we’ve answered the top queries from people who sought information about this topic. In this section, you’ll find plenty of additional facts about medical treatment and the forms that allow doctors to administer it.
You need a patient to sign a consent to treatment form before any services are rendered to show they were aware of what was about to happen and agreed to it. So long as the person is capable of giving consent, not in imminent danger of death, unconscious, or unable to communicate their needs and acquiescence, they must do so before any treatment. This includes everything from a cursory intake exam or a simple bandage to scheduling a major surgery. In short, you always need a consent to treatment form.
There are two types of consent in medical treatment, not four. The first and most widely used is the written form or signing a consent to treatment form. Secondly, in some cases, verbal consent is considered adequate, though this usually requires witnesses and/or must be followed up with a written form.
ᐅ The patient voluntarily waives the right to consent.
ᐅ The patient is incapacitated and cannot speak, write or otherwise consent at this time.
ᐅ Too little time to obtain consent, such as in an emergency where someone is dying
ᐅ People under 18 cannot generally give consent. Instead, a parent or guardian’s signature is necessary.
Doctors need to get consent before treating a patient because people have the right to determine what happens to their bodies. While there are a few circumstances where someone else can or must make those decisions, such as minors and adults who require care and supervision to thrive, most people, in most cases, have the legal right to choose what their bodies will be subject to. An excellent example of this in the modern era is the vaccine-takers and anti-vaxxers, both of whom can consent or refuse shots. Without a specific consent form, doctors can’t simply elect to make choices for competent adults.
You can always refuse consent for treatment. Moreover, you can refuse specific types of treatment while still accepting others. However, if you reject all treatments, then hospitals and other medical care providers are neither obligated nor able to treat you. You can also ask for a specific type of treatment instead of a less desirable alternative, though not every facility has the same devices and service capabilities. They can refuse if it’s not available or safe to accommodate your request.
A doctor can, in very rare circumstances, give treatment without consent. However, this only applies to save a life or help someone who cannot consent or refuse normally. For example, a person with breathing problems might not be able to say yes or no, and neither could someone who was knocked unconscious in an accident. Sometimes this may also apply to treating children without their parent’s consent, especially if the doctor suspects abuse or neglect.
Final Thoughts
Doctors and other medical practitioners need to collect a signed consent for treatment form before rendering services. These forms protect the facility and physician or other medical personnel by showing clearly that the person treated knew what was going on and permitted it or even requested it in some instances. If you are the patient in question, you have the right to consent or refuse any treatment, up to and including life-saving treatments. If you have questions or concerns about signing your informed consent, you should discuss them with your doctor or other relevant medical personnel before making critical decisions. Once given, consent for treatment is valid until it expires, or absent an expiration date, until revoked.
