INFORMED 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]