Patient Info

Patient Full Legal Name *

Patient Date of Birth *

Patient Age

Patient Address *

Patient Phone *

Patient is a Minor (under 18)

Parent/Guardian Full Name *

Guardian Relationship Select... Parent Legal Guardian Foster Parent Other

Guardian Phone

Procedure Provider

Procedure/Treatment Name *

Detailed Procedure Description *

Purpose of Procedure

Physician/Provider Name *

Physician Specialty

Healthcare Facility Name *

Facility Address

Scheduled Procedure Date

Risks Consent

Risks and Benefits Have Been Explained

Known Risks and Complications *

Expected Benefits

Alternative Treatments Discussed

Alternative Treatment Options

All Questions Have Been Answered

Consent is Given Voluntarily

Authorization

Consent to Anesthesia

Blood Transfusion Authorization Select... Authorized if medically necessary Not authorized Only in life-threatening emergency

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Patient

Consent Duration Select... Single procedure only 30 days 90 days 6 months 1 year Ongoing until revoked

HIPAA Privacy Notice Acknowledged

Consent Date *

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