Internal Medicine Informed Consent Form Template

Patient Information

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

Consent for Treatment

I, ______________________, hereby authorize Dr. _________________ and other healthcare providers at [Practice Name] to provide medical evaluation, testing, and treatment as deemed necessary for my medical care.

Understanding of Treatment

• I understand that my physician will explain:
  • The nature of my medical condition
  • The proposed treatment or procedure
  • The risks and benefits of the proposed treatment
  • Alternative treatments and their associated risks
  • The risks of declining treatment

Acknowledgments

1. I understand that medicine is not an exact science, and no guarantees have been made regarding the outcome of my treatment.
2. I acknowledge that I have had the opportunity to discuss my condition and treatment options with my physician.
3. I understand that I may withdraw this consent at any time.

Authorization for Release of Information

I authorize the release of my medical information as necessary for:

• Treatment coordination
• Insurance claims processing
• Quality assurance activities

Financial Responsibility

I understand that I am financially responsible for any charges not covered by my insurance.

Signatures

Patient/Legal Guardian: _________________ Date: _________

Witness: _____________________________ Date: _________

Physician: ___________________________ Date: _________

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