Forms, consent and waiversForm
Patient consent form template
Record informed consent before a procedure: what will be done and why, the main risks and alternatives, that the patient's questions were answered, the fees, and how their records are kept.
Opens in the Salsox editor with 6 signing fields already placed for Patient and Clinician. Add their emails and send. The free plan sends 3 documents a month.
Who signs
- Patient
- Clinician (you)
Preview
Consent to Treatment
Clinic: BrightSmile Dental Clinic Patient: Mr. Augustine Boakye, born 14 March 1985 Clinician: Dr. Akua Sarfo
1. Proposed treatment
root canal treatment of the lower right first molar, under local anaesthetic, over two appointments.
Reason: to treat infection in the tooth's nerve and save the tooth.
2. Risks and alternatives
The main risks explained to me are temporary pain and swelling, a cracked tooth, a reaction to the anaesthetic, and in a small number of cases the need for retreatment or extraction.
The alternatives explained to me are extracting the tooth, with or without replacing it with a bridge or implant, or no treatment, which risks the infection spreading.
Patient initials: Initials · Patient
3. Questions and understanding
I have had the chance to ask questions, and they were answered to my satisfaction. I understand that I can change my mind and withdraw consent at any time before or during treatment, and that unexpected findings during treatment will be discussed with me where possible.
4. Fees
The fee for this treatment is GHS 1,600 for both appointments, excluding the final crown. Additional treatment will only be carried out after a new discussion and agreement.
5. Records and privacy
The clinic will keep my records confidential and securely, use them for my care and as the law requires, and share them only with my consent or where the law allows.
Patient consent
I consent to the treatment described above.
Patient signature: Signature · Patient Date: Date · Patient Name: Name · Patient
Clinician statement
I have explained the treatment, its risks and alternatives, and answered the patient's questions.
Clinician signature: Signature · Clinician Date: Date · Clinician
These templates are general starting points, not legal advice. Laws differ between countries and states: check that a template suits your situation, or ask a lawyer, before you rely on it.
About the Patient consent form template
Informed consent is a conversation between clinician and patient; the form is its record. It should show that the patient was told what the procedure is, why it is recommended, its main risks, the alternatives including doing nothing, and that their questions were answered before they agreed.
This template is structured around those elements, so a clinic can fill in the specifics for each procedure. It also covers the practical points patients care about: the fee, and how their records and personal information are handled, which health privacy laws in most countries require clinics to explain. The patient initials the risks and alternatives section, and both patient and clinician sign.
Requirements differ by country, profession and procedure; check your regulator's guidance, and use the clinic's own wording for high-risk procedures. Patients can sign on a tablet in the waiting room through Salsox.
- Signers
- 2
- Signing fields placed
- 6
- Details to fill in
- 9
How to use this template
Open it in Salsox
Choose Use this template. Sign up free if you have no account; the template opens straight after.
Fill in the details
Type your details into each blank, or start from the sample to see how it reads. Save it as your own template to reuse it.
Add signers and send
The editor already has every signature, date and initials field in place. Add each signer's email and send; they sign on their phone, and everyone gets the sealed copy with its audit trail.
Used in
Questions
What makes consent informed?
The patient understands what is proposed, why, the material risks, the alternatives including no treatment, and has had their questions answered, before agreeing freely.
Is a signed form enough?
The form records the conversation; it does not replace it. Regulators expect the clinician to explain and check understanding.
Can patients sign consent forms electronically?
In most countries, yes. Check your regulator's rules for particular procedures, and keep the signed copy in the patient's record.
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Send it for signature in minutes
Start from this template in Salsox: fill in the blanks, add your signers and send by email, WhatsApp or SMS. Signers sign one field at a time on their phone, and you can collect a payment in the same step.