Everything You Need to Include in Your Consent to Treatment Form

Consent to treatment forms are an absolute must when it comes to healthcare.

The purpose of these documents is to ensure that the patient is fully aware and accepting of a particular treatment. This not only helps to protect the rights of the patient, but also helps to protect the provider—having a signed consent to treatment form hinders the patient from coming back later and saying otherwise in a malpractice claim.

And it’s not just about upholding ethical values. Consent to treatment forms are also required by law in many states.

Though having a consent to treatment form isn’t necessary for all services and procedures (more on that below), it’s always a good idea for your practice to have a standard form ready to go when you need it.

And we’re here to help you do just that!

When You Need a Consent to Treatment Form

To be fair, consent to treatment is needed in nearly every healthcare situation so long as the patient is conscious and without a life-threatening emergency. If a patient is unconscious and at immediate risk, then consent is waived since it cannot be provided and the patient might otherwise die.

But consent can come in many forms. For example, if a patient is going to get blood drawn and willingly presents their arm for the task, then that can be considered consent. This remains true for any simple diagnostic test when your actions imply consent (e.g. lying down on the table for an X-ray).

However, when treatment is considered as putting the patient in a vulnerable position where they may not be able to resist or walk out, then written consent is required. Any procedure that could potentially pose a risk to the patient would fall under this category.

In these instances, the provider is required to present a consent to treatment form to the patient for their review and approval. Part of this process is ensuring that the patient fully understands the details of the treatment and has been given the opportunity to ask any questions or address any concerns.

As advised by the American Cancer Society, “Informed consent is a process that includes all of these steps:

• You [the patient] are told (or get information in some way) about the possible risks and benefits of the treatment.
• You are told about the risks and benefits of other options, including not getting treatment.
• You have the chance to ask questions and get them answered to your satisfaction.
• You have had time (if needed) to discuss the plan with family or advisors.
• You are able to use the information to make a decision that you think is in your own best interest.
• You share your decision with your doctor or treatment team.”

The patient must also be considered competent to give consent, so in cases where the patient is unable to consent, mentally ill, or a minor, then a parent or guardian must consent for them.

Creating Your Consent to Treatment Form

Some practices choose to keep their consent forms simpler, while others prefer to go into great detail—whatever the case, make sure the information you provide and approval you are asking for is clear to the patient.

Since the idea is for the patient to read and sign the document in agreement, be sure to write the copy in a first-person voice (e.g. “I authorize…” and “I understand that…”), with “I” being the patient.

Also leave a space at the top where the patient can print (or type!) their full name, birthdate, and today’s date. This will help avoid any confusion if there are questions about who filled out the form or when.

From there, here are some sections you should consider including on your consent to treatment form…

Consent

This first one is a no-brainer: Be sure to clearly state that the patient is authorizing your practice to perform the treatment or service.

Again, depending on your area of specialty, you may choose to keep this section more general (“I give consent for [practice name] to perform and provide medical care, tests, or procedures as agreed upon in the best interest of my health).

Or, if your office performs one specific service, you may choose to call it by name or detail it here. This could include specifying certain steps of the procedure or potential risks.

When including the name of your practice in this section, be sure to add any additional team members who may be participating—PAs, nurses, technicians, staff, etc. This helps to collectively protect your practice, not just the physician.

Also, regardless if the form goes into detail about the particular treatment or not, you should include copy that allows the patient to acknowledge that he or she fully understands the procedure/service and has been given the opportunity to ask questions. This would be a good section to have the patient initial, which brings us to…

Signatures & Initials

Obviously you need a signature at the end of your form to signal that the patient understands and agrees to everything that is included in the document.

However, to cover all your bases (and make sure that the patient is actually reviewing the entire form), it’s good practice to have patients mark their initials at each section.

This further exemplifies that they are aware of what they are consenting to by signing the form and ensures that they cannot come back and dispute otherwise.

Digital Forms

Granted, consent to treatment forms can sometimes include a lot of material to read, and patients may resort to skimming the information as they stand at your office’s check-in desk or sit in the waiting room.

Fortunately, choosing digital forms is a great solution to both these rushed reviews and annoying office wait times. By using a trusted digital portal to deliver consent to treatment forms ahead of an appointment or procedure, you can feel more confident that patients will take the time to thoroughly read and understand the form.

That’s why IntakeQ makes it easy for your practice to create and send custom consent to treatment forms to your patients.

You may choose to make your digital consent to treatment forms more detailed so that the patient can learn about the procedure, or partner them with prep calls from your office that allow a member of your staff to describe the procedure in detail and answer any questions the patient may have.

Another bonus to using a digital version of the form is that you are diminishing the risk of losing the form and being unable to prove consent. By having everything initialed and signed electronically (yes, with IntakeQ your patients can even sign from their computer or digital device) you can feel secure that your forms are properly saved and protected.

We can even take your existing paper forms and transfer them into digital forms for you—talk about easy!

Protect your practice and your patients with these 10 simple steps to getting consent.

The Bottom Line

As healthcare providers, there are many steps to take to ensure that things are being done right—both ethically and legally.

It’s important to know what you may or may not be responsible for, and make sure that those obligations and/or expectations are clearly understood between the practitioner and the patient.

Having a buttoned-up consent to treatment form is the only way to guarantee the protection of both the patient and your practice, so it is critical to never overlook this step in the treatment process.

Communication is key, and we’re here to help make the communication between you and your patients as clear and convenient as possible.