Consent to a medical procedure template

Consent to a Medical Procedure

Date: Date

I, Patient or Guardian Name, ID number ID Number, confirm that Dr. Physician Name has explained to me the nature of Procedure Name, its benefits, possible risks and the available alternatives. I have had the opportunity to ask questions, and I freely consent to this procedure being performed on Patient Name at Facility Name.

I know I may refuse the procedure or withdraw my consent before it starts.

Patient / guardian: Patient or Guardian Name

Signature: Signature

Physician: Physician Name

Witness: Witness Name

Date and time: Date – Time