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Questionnaire template

Patient Treatment Consent Form

Records a patient's or representative's informed consent to a named treatment, plus research and photography choices.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Patient and Signer

  1. This form records your consent to a proposed treatment or procedure. Please read the information sheet you were given and ask the care team about anything that is unclear before you complete it.

  2. Patient's full name

    Open answer

  3. Patient's age

    A number from 0 to 120

  4. Who is completing this form?

    Choose one:

    • The patient
    • A parent or guardian
    • A legal representative

  5. Your full name

    Condition: Shown when someone completes the form on the patient's behalf

    Open answer

  6. What is your relationship to the patient?

    Condition: Shown when someone completes the form on the patient's behalf

    Open answer

Information Received

  1. Which treatment or procedure is this consent for?

    Open answer

  2. Has the care team explained each of the following to you?

    • Why the treatment is recommended
    • What benefits to expect
    • The possible risks and side effects
    • Other options, including having no treatment
    • That you may change your mind at any time

    For each row: choose one:

    • Yes
    • No

  3. Do you have any questions that have not yet been answered?

    Choose one:

    • Yes
    • No

  4. What would you still like to know? The care team will answer before you go ahead.

    Condition: Shown when questions remain

    Open answer

Consent Decisions

  1. Do you agree to the treatment or procedure named above?

    Choose one:

    • Yes
    • No

  2. If you wish, tell us why you have decided not to go ahead.

    Condition: Shown when consent is declined

    Open answer

  3. Do you agree that anonymised information from your records may be used for medical research?

    Choose one:

    • Yes
    • No

  4. Do you agree to clinical photographs being taken for your medical record?

    Choose one:

    • Yes
    • No

Confirmation

  1. Please confirm the statement below.

    Choose any that apply:

    • I confirm that the details above are correct and that I have made these decisions freely

  2. Type your full name as your signature

    Open answer