[Clinic name]
Controlled document
[Address]
[Registration or licence number]
Consent to treatment form
1About this form
- 1.1This form records the patient's consent to the treatment named below, and the information they were given before they agreed.
- 1.2Consent is a conversation before it is a signature, so the clinician records what was discussed, in a language the patient understands.
2The patient
- Full name
- Date of birth
- Record number
- Language used
- Interpreter, if used
3The treatment
- Treatment or procedure
- Intended benefit
- Clinician
- [Name, registration number]
- Cost, if any
4What was explained
- The nature of the treatment and what it involves.
- The serious and frequent risks, including [specific risks].
- The alternatives, including no treatment.
- The aftercare, and who to contact if something goes wrong.
- That the patient may withdraw consent at any time before the treatment.
- Any use of software or AI in recording the consultation, and how the record is kept.
5The patient's agreement
- 5.1I have read this form or had it read to me, my questions have been answered, and I agree to the treatment described.
- Patient signature
- Date and time
- Person with parental responsibility or legal authority, if any
6The clinician's confirmation
- 6.1I have explained the treatment, its risks and its alternatives, and I believe the patient understands and has capacity to decide.
- Clinician signature
- Date and time
7Revisiting consent
- 7.1Consent is confirmed again on the day of treatment, and recorded in the note.
- 7.2A copy of this form is kept on the patient's record, where it can be shown at an HIS inspection.
8Where this sits in the HIS framework
- DirectionPerson-centred planning and care
- ResultsDignity and respect
AAppendix, Aesthetic consultation and consent record
- A.1Patient reference ______ Date and time of consultation ______
- A.2Prescriber ______ Registration body and number ______
- A.3Medical history, medicines, GP ______
- A.4What the patient wants ______ What was advised ______
- A.5Risks, side effects and alternatives discussed ______
- A.6Price quoted ______ Unlicensed or off-label use explained ______
- A.7Date of treatment ______ Same day, patient's choice recorded ______
- A.8Consent signed by patient ______ and practitioner ______ on ______
- A.9Product ______ Dose ______ Batch ______ Expiry ______
- A.10Injection sites recorded ______ Aftercare given ______