Adam Frankel
General Counsel · Technology & AI
15+ years as General Counsel to technology, cloud & AI companies
Medical Consent Form (US) by OLL
Open Legal LibraryUpdated 7 Oct 2026
A comprehensive medical intake and consent form for patients at US health centers or outpatient clinics. It combines general consent to treatment, optional procedure-specific informed consent, acknowledgement of privacy practices, and financial responsibility into a single signing.
MEDICAL CONSENT FORM (US)
Note: This form collects, in one signing, the consents a clinic or community health center needs before it treats a new patient: general consent to care, an optional consent to a named procedure, acknowledgment of the privacy notice, financial responsibility, contact permissions, language assistance, and a signature block for a parent or other representative. Complete every yellow field and complete Exhibit A. Where a section offers Option A or Option B, keep one and delete the other.
Note: Two things stay out of this form on purpose. First, a HIPAA authorization to release records to a third party (an employer, a lawyer, a relative) must be a separate document: federal privacy rules prohibit combining an authorization with any other document and prohibit making treatment depend on signing one (45 C.F.R. 164.508). Second, a procedure-specific informed consent discussion is governed by the law of your state. Section 2 gives you a form for it, but the conversation with the practitioner is what the law requires, not the signature alone.
This Medical Consent Form (this "Consent") is given on [date of consent] by [full name of the patient], date of birth [date of birth of the patient] (the "Patient"), or by the Patient's representative named in Section 10, to [legal name of the health center] of [address of the health center], telephone [telephone number of the health center] (the "Health Center"). Where this Consent says "I" or "me", it means the Patient, or the representative signing for the Patient.
Note: Use "Health Center" for any clinic, medical practice, community health center, or other outpatient provider. The form is written for outpatient care. A hospital admission uses the hospital's own conditions of admission, which carry additional federal requirements.
1. CONSENT TO TREATMENT
1.1 General consent. I consent to examination, diagnosis, treatment, and routine care at the Health Center by its physicians, nurse practitioners, physician assistants, nurses, behavioral health practitioners, dental practitioners, and other licensed staff, and by students and trainees working under their supervision. Routine care includes taking a medical history, physical examination, vital signs, laboratory tests, imaging, vaccinations, prescribing and administering medication, and minor office procedures.
1.2 What this consent does not cover. This general consent does not cover surgery, anesthesia or sedation, invasive procedures, or any treatment that the Health Center's policies or the law of the state in which I am treated require to have its own written consent. For those, I will be asked to sign Section 2 of this form or a separate consent after the practitioner has explained the procedure to me.
1.3 No guarantee. I understand that medicine is not an exact science and that no one has promised me a particular result.
1.4 My questions. I have had the chance to ask questions about my care and to have them answered in a way I understand.
This is a preview. The full template is free on GitLaw.
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About this template
What is this template?
This document is a combined clinical intake form for outpatient settings. It is not a HIPAA authorization for third-party record release, which federal rules require to be a separate document. It contains specific sections for general treatment consent, financial responsibility assignments, and federal nondiscrimination disclosures.
When should you use it?
Use this form for new patient registration at a clinic or when a specific procedure requires documented informed consent. Use a separate HIPAA Release of Information form if the patient needs to share records with an employer or lawyer.
What's inside
| Clause | Name | What it does |
|---|---|---|
| 1 | CONSENT TO TREATMENT | Patient grants general consent for diagnosis and routine care by licensed staff, excluding surgery or invasive procedures. |
| 2 | CONSENT TO A SPECIFIC PROCEDURE OR TREATMENT | Provides optional fields to record informed consent for a named procedure, including discussed material risks and alternatives. |
| 3 | MY RIGHT TO REFUSE OR WITHDRAW CONSENT | Patient retains the right to refuse any recommended treatment or withdraw this consent at any time by notifying staff. |
| 5 | FINANCIAL RESPONSIBILITY AND INSURANCE | Patient accepts responsibility for charges not paid by insurance, including copayments, deductibles, and non-covered services. |
| 6 | NOTICE OF PRIVACY PRACTICES | Patient acknowledges receipt of the Health Center's privacy notice and understands information is shared for treatment and payment. |
| 8 | LANGUAGE ASSISTANCE AND ACCESSIBILITY | Health Center commits to providing qualified interpreters free of charge and records the Patient's preferred language. |
Who it's for
- a US outpatient clinic or community health center processing a new patient intake
- a healthcare provider obtaining informed consent for a specific minor procedure or sedation
- a patient representative signing on behalf of a minor or incapacitated adult
- a Federally Qualified Health Center (FQHC) managing a sliding fee discount program
How long it runs and how it's signed
How long
Runs for a fixed period
Stated duration
[duration of consent]
Notice to end it
withdrawal by telling staff
Signed by
Patient, Personal Representative, Health Center Witness, Interpreter
Witness
Required
Notarisation
Not required
Also needed
Exhibit A completion
Law it's drafted under
Refers to
45 C.F.R. 164.508
Refers to
42 C.F.R. 482.13(b)(2)
Refers to
47 C.F.R. 64.1200
Refers to
45 C.F.R. 92.201
Refers to
15 U.S.C. 7001(a)
Jurisdiction
General (US)
Document info
GitLaw document. Document created on Wed Oct 7th, 2026. Last updated on Wed Oct 7th, 2026.
This document is public
Licensed under CC BY 4.0 (Attribution).
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