Medical consent form

Consent to Treatment Informed consent for services This consent is between ____ (Client’s full name) (the “Client”) and ____ (Provider or practice name) (the “Provider”). It explains the service, what to expect and the Client’s rights, so that the Client can decide whether to go ahead. Section 1: The service 1.1 The Provider will provide the following service to the Client: ____ (Describe the service) 1.2 The Provider will explain what is being done and why, answer the Client’s questions, and respect the Client’s choices about their own care. 1.3 Sessions will take place ____ (Where sessions take place) and are expected to last about ____ (How long each session is). Section 2: What to expect, and what I understand 2.1 The service can help, but results cannot be promised and they differ from person to person. I understand that I may feel uncomfortable at times, and that I may stop or pause at any time. 2.2 I understand that the Provider’s service is not a substitute for care from a doctor or another licensed professional where I need it, and the Provider will tell me if it thinks I should see one. 2.3 I will give the Provider accurate and complete information that is relevant to the service, and tell it about any change in my health or circumstances that could affect it. 2.4 I understand that I have the right to ask questions at any time, to say no to any part of the service, and to end it. Section 3: How my information is handled 3.1 The Provider will keep what I tell it, and the records it makes, private and secure, and will share them only with people who need them to provide the service and who are bound to keep them private. 3.2 The Provider may have to share information without my consent where the law requires it, or where it believes there is a serious risk of harm to me or to someone else. Where it is lawful and safe to do so, it will tell me first. 3.3 I may ask to see the records the Provider keeps about me, and to have mistakes corrected. The Provider will keep records for ____ (How long records are kept) after the service ends, unless the law requires longer. Section 4: Benefits, risks and alternatives 4.1 The possible benefits of the service are: ____ (Possible benefits) 4.2 The possible risks or side effects, and how likely they are, are: ____ (Possible risks or side effects) 4.3 Alternatives to this service, including doing nothing, were discussed with me: ____ (Yes, the alternatives were explained to me) Yes, the alternatives were explained to me. I understand I can choose a different provider or approach at any time. Section 5: My rights 5.1 I have the right to be treated with dignity and respect, to receive an explanation I can understand, to give or refuse consent, to ask for a second opinion, to see my records, and to make a complaint without it affecting the service I receive. 5.2 If I want to make a complaint, I can do so in writing to the Provider at ____ (Where to send a complaint). The Provider will reply within fourteen days. Section 6: Fees, appointments and cancelling 6.1 Fees for the service are: ____ (Fees and how they are paid). 6.2 If I cannot attend an appointment I will tell the Provider at least ____ (Notice needed to cancel) before it. A session cancelled later than that, or missed, may be charged for. 6.3 Either of us may end the service by telling the other. I will pay for sessions already given. Section 7: In an emergency 7.1 The Provider is not an emergency service. If I am in danger, I will call my local emergency number. My emergency contact is: ____ (Emergency contact’s name), ____ (Their phone). ____ (I have read and understood this form, I have had the chance to ask questions, and I agree to the service.) I have read and understood this form, I have had the chance to ask questions, and I agree to the service. Signatures By signing below, each party agrees to this document and confirms that the person signing has the authority to do so. Client ____ (Printed name) Printed name ____ (Client signature) Signature ____ (Client date signed) Date Provider ____ (Printed name) Printed name ____ (Title or capacity) Title or capacity ____ (Provider signature) Signature ____ (Provider date signed) Date