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Questionnaire template

Consent to Treatment

Records a patient's understanding of a proposed treatment, communication preferences and their consent decision.

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Healthcare · Patient consent. All Healthcare templates

Questions in this template

Who Is Completing This Form

  1. This form records your decision about the treatment your care team has proposed. Please answer each question honestly; you may ask the team for more information at any point.

  2. Who is completing this form?

    Choose one:

    • The patient
    • Parent or guardian
    • Legal representative

  3. What is your relationship to the patient?

    Condition: Shown when someone other than the patient completes the form

    Open answer

Information You Received

  1. Has a member of the care team explained the proposed treatment to you?

    Choose one:

    • Yes
    • No

  2. How well do you understand each of the following?

    • Why the treatment is being recommended
    • The benefits you can expect
    • Possible risks and side effects
    • Other options, including choosing no treatment

    For each row: choose one:

    • Fully
    • Partly
    • Not at all

  3. Were you given the chance to ask questions?

    Choose one:

    • Yes
    • No

  4. Do you still have questions that have not been answered?

    Choose one:

    • Yes
    • No

  5. Please write down the questions you still have, so the team can answer them.

    Condition: Shown when questions remain

    Open answer

Communication and Information Sharing

  1. How would you prefer us to contact you about your treatment?

    Choose one:

    • Phone
    • Email
    • Text message
    • Post

  2. May we leave detailed messages about your care if you cannot be reached?

    Choose one:

    • Yes
    • No

  3. May we share details of this treatment with your family doctor?

    Choose one:

    • Yes
    • No

Your Decision

  1. Do you agree to go ahead with the proposed treatment?

    Choose one:

    • Yes, I consent
    • No, I do not consent
    • I need more time to decide

  2. What would help you decide, or what concerns you about the treatment? (optional)

    Condition: Shown when consent is not given

    Open answer