An informed consent form records a patient’s agreement to a procedure or treatment, after a clinician has explained what it involves, why it’s recommended, its benefits and risks, and the other options, including doing nothing. Copy the free form with a consent discussion note, see a colonoscopy with sedation and a hip fracture repair where capacity was assessed, and check what goes in each part.
Blank informed consent form template
FreeINFORMED CONSENT FORM Consent to a procedure or treatment [Organization name] [Department, address, and phone] THE PATIENT Name: [Full name] Date of birth: [Date] Record number: [Number] WHO IS GIVING CONSENT Consent given by: [The patient, a substitute decision-maker, or a parent or guardian] If not the patient: [Name, relationship, and the authority they decide under, such as a power of attorney for health decisions, a guardianship order, or the law where you practice] Why the patient isn't deciding: [The capacity assessment and its result, the patient's age, or not applicable] THE PROCEDURE OR TREATMENT Procedure: [Plain words first, then the medical term] Side, site, or level: [Left or right, site, or level, or not applicable] What will happen: [What is done, how long it takes, and what the patient will see and feel] Why it's recommended: [The condition, and what the procedure should find, treat, or prevent] Expected benefits: [What the patient can reasonably expect, and how likely it is] Extra steps that may be needed: [Such as a biopsy, removing a polyp, or a drain, and anything the patient does not agree to] RISKS Common risks: [Risks that happen often, even if minor, with the figures you quoted] Serious risks: [Rare risks that matter, such as bleeding, infection, injury to nearby organs, or death, with the figures you quoted] Risks for this patient: [Risks raised by their health, medicines, age, or work] If nothing is done: [What is likely to happen without it] ALTERNATIVES Other options: [Other tests or treatments, each with its main benefits and risks] Waiting or doing nothing: [What that would mean for this patient] ANESTHESIA OR SEDATION Type: [General, regional, sedation, local, or none] Discussed by: [The anesthesia professional or the clinician doing the procedure, and whether there is a separate anesthesia consent] After sedation: [No driving or important decisions for 24 hours, and an adult to take the patient home, or not applicable] WHO WILL DO IT Responsible clinician: [Name and role] Others taking part: [Residents, fellows, assistants, or students, and what each will do] IF THEY APPLY Blood products: [Agrees to a transfusion if needed, declines, or declines some products, with the alternatives discussed] Specimens and tissue: [What is sent to the lab, and how tissue is disposed of] Implants or devices: [Name and type, or not applicable] Photos or video: [For the record, for teaching, or none, and whether the patient agrees] Observers or students in the room: [Agrees or declines] THE DISCUSSION Information given: [Leaflet, diagram, video, or decision aid, in which language, and when] Questions asked: [The patient's questions, and the answers given] Interpreter: [Professional interpreter's name or ID, language, and in person, phone, or video, or not needed] Capacity: [Able to understand, appreciate, weigh, and communicate a choice about this decision, or how it was assessed and the result] Right to withdraw: [Told they can change their mind at any time before the procedure, and how to tell the team] CONSENT The procedure, its benefits and risks, and the alternatives have been explained to me. I have had the chance to ask questions, and they have been answered. I agree to the procedure described above, including the extra steps listed. I know I can withdraw my consent at any time before it starts. Patient or person giving consent: [Signature, printed name, date and time] Clinician: [Signature, printed name, role, date and time] Interpreter: [Signature, name or ID, date and time, if one was used] Witness: [Signature, printed name, date and time, only where your organization requires one] CONFIRMED ON THE DAY Reviewed with the patient: [Date, time, and by whom] Changes since signing: [Any change in health, the plan, or the patient's wishes, or none] CONSENT DISCUSSION NOTE FOR THE RECORD Date, time, and who was present: [Date, time, the patient, family or supporters, and the language used] Diagnosis and recommendation: [The condition and the procedure recommended] Discussed: [Benefits, risks with the figures you quoted, and alternatives including no treatment] Concerns and questions: [What the patient asked or worried about, and your answers] Capacity: [Your finding, and how you reached it] Decision: [Agrees, declines, or wants more time, and what happens next] Emergency: [If treatment couldn't wait and no one could consent: why, what was done, and who was told, or not applicable]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Endoscopy unit, day of the procedure, with a phone interpreter
Tuan Nguyen, born March 14, 1971, age 55. Gives his own consent. Speaks Vietnamese at home and some English. His son Minh came with him and offered to interpret; a professional Vietnamese interpreter was used by phone instead, ID 40217, and Minh stayed to listen.
Colonoscopy: a thin, flexible camera passed through the back passage to look at the whole large bowel, taking about 30 minutes. Why: a positive FIT stool test from his screening kit in September. Most positive results aren’t cancer, but about 3 to 5 in 100 people with a positive FIT have bowel cancer, and many more have polyps. Benefits: find the cause, remove polyps before they can become cancer, and find a cancer early if there is one. Extra steps he agrees to: removing polyps, taking biopsies, and a small ink tattoo to mark a spot to find again. A flat polyp larger than about 2 cm won’t be removed today: samples, a tattoo, and a separate discussion.
Common: bloating and cramping for a few hours; pressure during the test. Sedation: a brief drop in oxygen or blood pressure, treated in the room; his sleep apnea makes low oxygen a little more likely, so he’ll be watched closely. Serious: a tear in the bowel wall, about 1 in 1,000 to 3,000, more likely when a polyp is removed, which may need surgery and a hospital stay. Bleeding after polyp removal, about 1 in 100 to 300, up to 2 weeks later; it usually stops on its own or is treated at a repeat scope. A missed polyp or cancer, more likely if the bowel isn’t fully clear. Death: very rare. If nothing is done: the cause of the positive test stays unknown, and a cancer, if there is one, may be found later, when it’s harder to treat.
CT colonography: a scan of the bowel, with a bowel prep and a small tube to inflate the bowel, and no sedation. It can’t remove polyps or take samples, so anything it finds means a colonoscopy anyway. Repeating the stool test: not advised after a positive result. No test: as above. He chose colonoscopy.
Sedation: moderate sedation through an IV, midazolam and fentanyl, given by the endoscopy nurse under the endoscopist’s direction; he can ask for less or none. No driving or important decisions for 24 hours; Minh will drive him home and stay the night. Who: Dr. Anjali Patel, gastroenterologist, will do the whole procedure. Specimens: polyps and biopsies to the lab. Photos: images of the bowel go into his record; agrees. Observers: a nursing student in the room; agrees. Blood products: not relevant.
Written information in Vietnamese mailed 3 weeks before, with the bowel prep instructions. Questions: “Will it hurt?” Most people feel pressure and some cramping; the sedation helps, and he can ask for more. “What if you find cancer?” Biopsies and a tattoo, results in 1 to 2 weeks, and a referral that week. “Can Minh stay?” Yes, until the procedure room. Capacity: no concerns; through the interpreter, he explained back the reason, the tear and bleeding risks, and the CT option. Right to withdraw: he can ask to stop at any time, including during the test, and Dr. Patel will stop as soon as it’s safe.
Signed by Tuan Nguyen at 8:40 a.m. on November 3, 2026, in the pre-procedure area, before any sedation; Dr. Patel signed at 8:42 a.m. Interpreter ID on the form. Witness: not required by the unit’s policy. Copy given in Vietnamese and English. Note: discussed at 8:25 a.m. through a Vietnamese phone interpreter, son present. Colonoscopy for a positive FIT. Quoted: perforation 1 in 1,000 to 3,000, bleeding after polyp removal 1 in 100 to 300, missed lesions, and sedation risks a little higher with sleep apnea. Alternatives: CT colonography, or no test. Capacity not in doubt; explained back correctly. Agrees to colonoscopy with polyp removal, biopsies, and tattoo under moderate sedation; a large flat polyp to be sampled, not removed.
Orthopedic ward, evening of admission; surgery planned for the next morning
Eleanor Brooks, born June 2, 1946, age 80. Lives alone in an apartment; walks with a cane outdoors. Mild cognitive impairment diagnosed 2 years ago at a memory clinic; MoCA 22 out of 30 in April 2026. Her daughter, Ruth Brooks, is named in her power of attorney for health decisions. Eleanor asked for Ruth to join the discussion. Consent given by: Eleanor herself, after a capacity assessment. Ruth supports her and doesn’t decide while Eleanor can.
Left hip hemiarthroplasty: replacing the broken ball at the top of the thigh bone with a metal one, fixed with bone cement, through a cut on the side of the hip; about 90 minutes. Why: she fell at home this morning and broke the neck of her left thigh bone, and the ends have moved apart. A break like this won’t heal well enough to walk on. Benefits: much less pain, getting out of bed the day after surgery, and the best chance of walking again. About half of people get back to walking as they did before; most use a walker at first, and many spend some weeks in a rehabilitation unit.
Confusion after surgery, called delirium: about 1 in 3, more likely with memory problems; it usually settles over days to weeks, but memory can end up a little worse. Blood transfusion: needed by about 1 in 3. Infection: 1 to 2 in 100. Blood clots in the leg or lungs: 1 to 3 in 100, despite blood thinners. Dislocation of the new hip: 1 to 3 in 100. A reaction to the bone cement: a drop in blood pressure or oxygen during surgery, uncommon, and rarely fatal. Leg length difference, a break around the implant, or nerve injury: uncommon. Heart attack, stroke, or pneumonia: more likely at her age. Death within 30 days: about 5 to 10 in 100 people with a hip fracture, mostly from the strain of the injury and other health problems. If nothing is done: weeks in bed with pain, and high risks of pneumonia, clots, pressure sores, and dying.
Fixing the break with screws: a smaller operation, but with a break like hers, up to 1 in 3 need a second operation. Total hip replacement: offered to people who walk well and have no memory problems; a bigger operation, with a higher risk of dislocation for her. No operation: as above; for people too unwell for surgery or near the end of life. Waiting: more time in bed, and more complications, the longer surgery is put off.
Anesthesia: discussed separately with Dr. Kenji Sato, anesthesiologist, who recorded her consent on the anesthesia form: a spinal anesthetic with light sedation. A nerve block at the top of the thigh was given in the emergency department at 11 a.m. Who: Dr. Daniel Osei, orthopedic surgeon, with Dr. Priya Raman, orthopedic resident, who will do parts of the operation under his direct supervision; Eleanor agrees. Blood products: agrees to a transfusion if needed. Implant: cemented hemiarthroplasty. Photos: none. Observers: a medical student in the room; agrees.
6:30 p.m., in a quiet side room, hearing aids in and glasses on. Last opioid dose 2 hours before; pain 2 out of 10 at rest. 4AT 2, in keeping with her known memory problem; no delirium. Capacity for this decision: she understood she had broken her hip and needed “a new half hip”; saw that it applied to her: “If I don’t, I’ll be stuck in bed”; weighed it: worried about getting confused, and decided walking again mattered more; gave a clear choice that didn’t change. At 7:15 p.m. she recalled the main points with one prompt. Able to make this decision. Ruth asked whether the confusion would go away: usually, over days to weeks; familiar faces, glasses, hearing aids, and sleep at night help, and family can visit any time. Eleanor asked if she’d be awake: drowsy, with no feeling from the waist down.
Signed by Eleanor Brooks at 7:20 p.m. on November 5, 2026, with a large-print copy of the risks for her and for Ruth. Dr. Osei signed at 7:22 p.m. Witness: Grace Mensah, ward nurse, as the hospital requires; she saw Eleanor sign. Left hip marked, with Eleanor. Next morning at 7:45 a.m., Dr. Osei went over it again with her: 4AT 1, no change in her health or wishes, and she still agrees.
November 5, 2026, 6:30 to 7:20 p.m. Discussed with Eleanor Brooks; daughter Ruth present at her request. Displaced left femoral neck fracture; cemented hemiarthroplasty recommended. Quoted: delirium about 1 in 3, transfusion about 1 in 3, infection 1 to 2 in 100, clots and dislocation 1 to 3 in 100 each, death within 30 days 5 to 10 in 100, cement reaction uncommon. Alternatives: screw fixation, total hip replacement, no surgery. Capacity assessed for this decision: able. Goals of care discussed separately and recorded on her goals of care form. Decision: agrees to surgery tomorrow morning, and to a transfusion if needed. If she can’t make later decisions after surgery, Ruth decides for her, using what Eleanor has said she wants.
Who the patient is, and who is making this decision: the patient, or, if they can’t, a substitute decision-maker or a parent.
Avoid: Asking a relative to sign because they’re in the room. If the patient can make this decision, the consent is theirs, even when family helps.
What will be done, in words the patient would use, and what it’s for.
Avoid: “And any other procedure the surgeon thinks necessary.” Name the likely extra steps. Anything else needs a new discussion, unless it can’t wait.
The risks a reasonable person in the patient’s position would want to know, and any that matter to this patient: common ones, even if minor, and rare ones that are serious.
Avoid: “Risks explained.” Write which risks you named and the numbers you gave, so the record shows what the patient heard.
The other reasonable options, including waiting or doing nothing, each with its main benefits and risks.
Avoid: Leaving out an option because you don’t do it. If it’s reasonable, tell the patient it exists.
How the patient will be kept comfortable and who will do the work, plus the items that only apply to some procedures.
Avoid: Not mentioning that a trainee will do part of the procedure. Say who will do what, and record that the patient agreed.
Consent is a conversation, and the form records it. Note what the patient was given, what they asked, and how you knew they understood.
Avoid: Letting a family member interpret. Use a professional interpreter, and record their name or ID.
Signatures show the discussion took place. What a valid form needs differs by where you practice and by organization, so follow your organization’s policy.
Avoid: Treating the witness’s signature as proof the patient understood. It only confirms who signed; your note shows what they understood.
A short note for the record, in your own words, of the conversation behind the signature.
Avoid: Leaving it to the form alone. The note is where the questions, the capacity finding, and the reasons for the decision live.
The form is evidence of a discussion, not a stand-in for one. Note who explained what, the questions asked, and the answers given.
Write the risks you named and the figures you gave. They are what you quoted for this patient, from your own results or published ones, not a fixed rule.
Dementia, mild cognitive impairment, or old age don’t settle it. Assess capacity for this decision, at this time, after treating pain and anything reversible, and write down how.
After a sedative or on the way into the room, the patient can’t weigh anything. Give information in advance, take consent while there’s time to think, and confirm it on the day.
Vero Scribe drafts the consent form and the discussion note in your template from the conversation, with the patient’s consent, or from your dictation: the procedure, the risks and figures you quoted, the questions asked, capacity, and the decision. You review and edit every section, then copy it into your record or export it to Word or PDF for signing. Vero works in 60+ languages.
The patient and who is giving consent; the procedure in plain words, why it’s recommended, and the expected benefits; the common and serious risks, with the figures you quoted; the alternatives, including doing nothing; anesthesia or sedation; who will do it; blood products, photos, or students, where they apply; the questions asked; any interpreter; capacity; the right to withdraw; and signatures with the date and time, plus a witness where your organization requires one.
The patient, if they have capacity for this decision. If they don’t, a substitute decision-maker: someone named in a power of attorney for health decisions, a court-appointed guardian, or the relative the law where you practice puts first. For a child, a parent or guardian, unless the young person can consent for themselves where you practice.
Ask whether the patient can understand the information, appreciate how it applies to them, weigh the options, and communicate a choice. Capacity is judged for one decision at one time, so a person with memory problems may still be able to consent to surgery. If there’s time, treat pain, delirium, and other reversible causes first, and record how you reached your finding.
Only where your organization’s policy or the law where you practice requires one. A witness confirms who signed; they don’t confirm the patient understood. Taking consent is the clinician’s job: the one doing the procedure, or one who knows it well enough to explain the risks and answer questions.
Yes, when waiting would put the patient’s life or health at serious risk, they can’t consent, and no one who can decide for them is available. Give only the treatment that can’t wait, respect a refusal you know they made while able, such as a refusal of blood, and record why you went ahead.
Often, yes. Consent can be spoken, written, or shown by actions, like holding out an arm for a blood test. Many organizations ask for a signed form for surgery, anesthesia, sedation, transfusion, and other higher-risk care. Either way, note the discussion in the record.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient leaving or refusing care: the recommendation, capacity, risks in plain words, alternatives, signature or refusal to sign, and the care still given.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Screening questions, consent or declination, and a record of each dose: lot, expiry, site, observation, and the next dose due.
Consent to clinical photos, video, or audio: what is recorded, each use chosen separately, the device, storage, and withdrawal.
Patient-specific consent forms from your clinic’s own templates.
Consent forms for using Vero’s AI scribe, to download for your practice.
Consultations, perioperative context, and follow-up, drafted for your review.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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