Comprehensive Medical Informed Consent Template

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: _______________ Date: _____________________

Purpose and Nature of Treatment

I, _________________________, hereby authorize Dr. _________________________ and their associated healthcare providers at _________________________ to provide medical evaluation, testing, and treatment as deemed necessary for my medical care.

Understanding and Acknowledgment

I understand that:

• This consent encompasses routine diagnostic procedures, examinations, and medical treatments including, but not limited to:
  • Physical examinations
  • Blood draws and laboratory tests
  • Administration of medications
  • Routine medical procedures

Risks and Benefits

• I acknowledge that no guarantees have been made regarding the outcome of any treatment
• Common risks have been explained to me, including potential side effects of medications and procedures
• I have had the opportunity to ask questions about my treatment options

Financial Responsibility

I understand that I am responsible for any charges related to my care, regardless of insurance coverage.

Right to Refuse Treatment

I understand that I have the right to refuse any proposed treatment or procedure at any time.

Signatures

Patient/Legal Guardian: _____________________ Date: ________ Witness: _________________________________ Date: ________ Healthcare Provider: _______________________ Date: ________

Revocation

This consent will remain in effect until revoked in writing.

This template should be customized to meet specific practice needs and local legal requirements.