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Medical_Consent_Form_With_Witness (1)

The document is a Medical Consent Form that collects patient information, emergency contact details, and medical history. It authorizes healthcare providers to administer necessary medical treatment and outlines the patient's rights regarding consent. Additionally, it includes sections for minor consent, declarations, and witness statements.

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ivyroberts254
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18 views2 pages

Medical_Consent_Form_With_Witness (1)

The document is a Medical Consent Form that collects patient information, emergency contact details, and medical history. It authorizes healthcare providers to administer necessary medical treatment and outlines the patient's rights regarding consent. Additionally, it includes sections for minor consent, declarations, and witness statements.

Uploaded by

ivyroberts254
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MEDICAL CONSENT FORM

Confidential Patient Information and Authorization for Treatment

1. Patient Information
Full Name: ____________________________________________

Date of Birth: ____ / ____ / _______ Age: _______ Gender: ☐ Male ☐ Female ☐ Other

Phone Number: ___________________

Address: ________________________________________________

2. Emergency Contact
Full Name: ____________________________________________

Relationship to Patient: ____________________________

Phone Number: ___________________

3. Medical History (Optional)


List any known allergies, chronic conditions, or current medications:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

4. Consent to Medical Treatment


I, the undersigned, hereby authorize the healthcare providers at:
Facility/Organization Name: _________________________________
to administer medical examinations, diagnostic procedures, treatment, and/or necessary
medical care deemed advisable for myself or my dependent.

I understand the purpose, risks, and possible side effects of any recommended procedures. I
understand that no guarantees have been made regarding the results of treatment and that I
may withdraw this consent at any time in writing.
5. Emergency Medical Treatment
In the event of an emergency where I (or the patient) am unable to provide consent, I
authorize the healthcare team to perform necessary treatment, including hospitalization,
anesthesia, or surgery, if required.

6. Minor Consent (If Patient is Under 18 Years)


Name of Parent/Guardian: ____________________________________

Relationship to Minor: _______________________________________

☐ I give consent for the above-named minor to receive medical treatment.

7. Declaration and Signatures


I have read and fully understand this consent form. I confirm that I am legally authorized to
give consent for treatment and that all information provided is accurate to the best of my
knowledge.

Signature of Patient/Parent/Guardian: __________________________

Name (Printed): ___________________________________________

Date: ____ / ____ / _______

8. Witness Statement
I hereby declare that the above-named individual signed this document in my presence and
appeared to understand the nature and purpose of this consent.

Witness Full Name: ________________________________________

Signature of Witness: _______________________________________

Relationship/Title: __________________________________________

Date: ____ / ____ / _______

9. For Healthcare Provider Use Only


Name of Attending Provider: _________________________________

Signature: __________________________

Date: ____ / ____ / _______

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