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Healthcare Form Templates

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General Treatment Consent Form
Patient Full Name
Date of Birth
Treating Provider
Proposed Treatment or Procedure
Risks and Complications
Alternative Treatments
Questions Answered Satisfactorily
Treatment Consent Agreement
Sign
Submit
Consent

General Treatment Consent Form

A comprehensive consent form for general medical treatment, covering patient acknowledgment of procedures, risks, and alternatives.

2 pages•14 fields•HIPAA-ready
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Patient Name
Date of Birth
Test Type & Indication
Select...
Scope of Testing Explained
Potential Results & Limitations
Secondary Findings Preference
Family Implications Acknowledged
Genetic Privacy & GINA Rights
Submit
Consent

Genetic Testing Consent Form

Informed consent for genetic and genomic testing covering test purpose, potential findings, implications for family members, data privacy, and right to decline results. Required for clinical and predictive genetic testing.

2 pages•14 fields•HIPAA-ready
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Patient Name
Date of Birth
Prescribing Provider
Medication Name and Dosage
+
Add
Condition Being Treated
Side Effects Reviewed
Drug Interactions Acknowledged
Lab Monitoring Schedule Agreed
Submit
Consent

High-Risk Medication Consent

Informed consent for high-risk medications including biologics, controlled substances, and teratogenic drugs. Documents risk acknowledgment, monitoring requirements, and patient education completion.

2 pages•14 fields•HIPAA-ready
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High-Risk Medication Consent Form
Patient Name
Medication Name & Dosage
+
Add
Indication for Therapy
Contraindication Screening
REMS Enrollment Acknowledgment
Adverse Effects Acknowledged
Monitoring Schedule Reviewed
Emergency Instructions Reviewed
Submit
Consent

High-Risk Medication Consent Form

Informed consent for high-risk medication therapy covering drug-specific risks, required monitoring, REMS program enrollment, contraindications review, and patient acknowledgment. For controlled substances, biologics, and teratogenic agents.

2 pages•12 fields•HIPAA-ready
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HIV Testing Consent Form
Patient Full Name
Date of Birth
Test Type
Select...
Pre-Test Information Reviewed
Confidentiality Protections Acknowledged
Counseling Services Offered
Preferred Results Notification Method
Select...
Right to Decline Testing Acknowledged
Submit
Consent

HIV Testing Consent Form

A consent form for HIV testing that addresses pre-test counseling acknowledgment, confidentiality protections, and the patient's right to decline testing.

2 pages•12 fields•HIPAA-ready
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Mental Health Treatment Consent Form
Patient Full Name
Date of Birth
Therapist or Provider Name
Type of Treatment
Select...
Confidentiality Limits Acknowledged
Emergency Contact Name
Emergency Contact Phone
Cancellation Policy Acknowledged
Submit
Consent

Mental Health Treatment Consent Form

An informed consent form for mental health services covering therapy approaches, confidentiality limits, and patient rights in behavioral health treatment.

3 pages•14 fields•HIPAA-ready
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Minor Treatment Consent Form
Child's Name & Date of Birth
Parent/Guardian Name
Relationship to Child
Select...
Minor Treatment Consent
Sign
Designated Responsible Adults
Submit
Consent

Minor Treatment Consent Form

Parental/guardian consent for treatment of minors. Includes treatment authorization, emergency medical authorization, and designated responsible adults for pickup and decision-making.

2 pages•7 fields•HIPAA-ready
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Donor Name
Date of Birth
Donation Type
Select...
Surgical Risks Acknowledged
Psychological Evaluation Completed
Financial Disclosure Reviewed
Voluntary Participation & No Coercion
Right to Withdraw Acknowledged
Submit
Consent

Organ Donation Consent Form

Informed consent for organ and tissue donation covering donor evaluation, surgical risks, psychological screening acknowledgment, and post-donation care. For transplant centers and organ procurement organizations.

2 pages•10 fields•HIPAA-ready
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Orthodontic Treatment Consent Form
Patient Full Name
Date of Birth
Parent or Guardian Name
Treatment Type
Select...
Estimated Treatment Duration
Risks and Complications Reviewed
Oral Hygiene Requirements Acknowledged
Dietary Restrictions Acknowledged
Submit
Consent

Orthodontic Treatment Consent Form

An informed consent form for orthodontic treatment including braces, aligners, and retainers, covering treatment duration, risks, and patient responsibilities.

2 pages•14 fields•HIPAA-ready
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Pediatric Sedation Consent Form
Child's Name
Date of Birth
Child's Weight (kg)
Procedure Requiring Sedation
Sedation Level & Agent
Select...
NPO Fasting Status Verified
Allergy & Airway Assessment
Sedation Risks Acknowledged
Submit
Consent

Pediatric Sedation Consent Form

Informed consent for pediatric procedural sedation covering sedation level, agent selection, NPO status verification, monitoring plan, and parent/guardian authorization. For pediatric procedures, imaging, and dental sedation.

2 pages•14 fields•HIPAA-ready
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Photo & Video Consent Form
Patient Name
Purpose of Photography/Video
Usage Authorization (Medical/Education/Marketing)
Storage & Retention Acknowledgment
Right to Revoke Consent
Sign
Patient Signature
Sign here
Submit
Consent

Photo & Video Consent Form

Authorization for clinical photography and video recording. Covers purpose of documentation, usage rights, storage and retention, and patient right to revoke consent. For medical documentation and marketing.

1 page•6 fields•HIPAA-ready
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Physical Therapy Consent Form
Patient Full Name
Date of Birth
Referring Physician
Primary Condition or Diagnosis
Treatment Techniques Authorized
Risks of Physical Therapy Acknowledged
Home Exercise Program Commitment
Modalities Consent (e.g., E-Stim, Ultrasound)
Sign
Submit
Consent

Physical Therapy Consent Form

A consent form for physical therapy and rehabilitation services, covering treatment techniques, exercise programs, and patient participation expectations.

2 pages•13 fields•HIPAA-ready
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Patient Name
Cancer Diagnosis & Treatment Site
Radiation Modality
Select...
Prescribed Dose & Fractionation
Acute Toxicity Risks Acknowledged
Late Toxicity Risks Acknowledged
Fertility Preservation Discussion
Concurrent Chemotherapy Risks
Submit
Consent

Radiation Therapy Consent Form

Informed consent for radiation therapy covering treatment modality, fractionation schedule, acute and late toxicities, fertility preservation discussion, and simulation procedures. For radiation oncology departments and cancer centers.

2 pages•14 fields•HIPAA-ready
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Radiology & Imaging Consent
Patient Name
Date of Birth
Ordering Provider
Imaging Study Ordered
Reason for Exam
Contrast Agent Required
Prior Contrast Reaction History
Kidney Function Concerns
Submit
Consent

Radiology & Imaging Consent

Informed consent for diagnostic imaging procedures including CT scans, MRI with contrast, fluoroscopy, and interventional radiology. Covers radiation exposure, contrast agent risks, and pregnancy screening.

2 pages•15 fields•HIPAA-ready
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Research & Clinical Trial Consent
Participant Name
Study Title & Description
Research Participation Consent
Sign
Compensation Details
Investigator Signature
Sign here
Submit
Consent

Research & Clinical Trial Consent

Informed consent for research participation covering study description, risks/benefits, voluntary participation, data use, and right to withdraw. Compliant with IRB and FDA requirements.

3 pages•10 fields•HIPAA-ready
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Patient Full Name
Date of Birth
Treatment Type & Biologic Product
Select...
Target Anatomy / Treatment Area
Diagnosis & Clinical Indication
Risks & Complications Acknowledged
Contraindication Screening
Current Medications
+
Add
Submit
Consent

Stem Cell & Regenerative Medicine Consent Form

Stem cell therapy consent form for regenerative medicine clinics offering stem cell injections, PRP therapy, and biologic treatments. Covers treatment details, risks and benefits, contraindications, photo documentation, payment, and informed consent.

3 pages•14 fields•HIPAA-ready
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Substance Abuse Treatment Consent Form
Patient Full Name
Date of Birth
Treatment Program Type
Select...
Substances of Concern
Medication-Assisted Treatment Consent
Drug Testing Policy Acknowledged
42 CFR Part 2 Confidentiality Acknowledged
Emergency Contact Name
Submit
Consent

Substance Abuse Treatment Consent Form

A specialized consent form for substance abuse and addiction treatment programs, addressing 42 CFR Part 2 confidentiality protections and treatment modalities.

3 pages•15 fields•HIPAA-ready
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Surgical Consent Form
Patient Name
Procedure Description
Surgical & Anesthesia Consent
Sign
Witness Signature
Sign here
Submit
Consent

Surgical Consent Form

Informed consent for surgical procedures including procedure description, risk acknowledgment, anesthesia consent, and e-signature capture. Required documentation for pre-operative workflows.

2 pages•5 fields•HIPAA-ready
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Patient Full Name
Date of Birth
Tattoo Location & Size
Ink Colors Present
Fitzpatrick Skin Type
Select...
Prior Removal Attempts
Medical History & Contraindications
Pre-Treatment Photo Documentation
Take photo
Submit
Consent

Tattoo Removal Consent Form

Tattoo removal consent form for laser tattoo removal clinics and dermatology practices. Covers treatment area documentation, skin type assessment, photo authorization, risks acknowledgment, payment collection, and informed consent for laser procedures.

2 pages•12 fields•HIPAA-ready
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Telehealth Consent for Minors Form
Minor Patient Full Name
Patient Date of Birth
Parent or Guardian Full Name
Guardian Phone Number
Guardian Email Address
Patient Location During Visit
Technology and Privacy Risks Acknowledged
Limitations of Telehealth Acknowledged
Submit
Consent

Telehealth Consent for Minors Form

A parental or guardian consent form for providing telehealth services to minor patients, covering technology requirements, privacy considerations, and limitations of virtual care.

3 pages•15 fields•HIPAA-ready
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Telehealth Consent Form
Patient Name
Telehealth Consent & Privacy Agreement
Sign
Emergency Contact & Location
Submit
Consent

Telehealth Consent Form

Consent for telehealth and virtual visit services. Covers technology requirements, privacy expectations, emergency protocols, and authorization for remote healthcare delivery.

1 page•3 fields•HIPAA-ready
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Vaccination Consent Form
Patient Full Name
Date of Birth
Vaccine(s) Requested
Allergies to Vaccine Components
Currently Pregnant or Immunocompromised
Recent Illness or Fever
Previous Adverse Reaction to Vaccines
VIS Received and Reviewed
Submit
Consent

Vaccination Consent Form

A consent form for vaccine administration that captures patient screening questions, vaccine information acknowledgment, and authorization to immunize.

2 pages•16 fields•HIPAA-ready
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ACE (Adverse Childhood Experiences) Screening
Patient Name
Date of Birth
Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Domestic Violence in Household
Submit
Screening

ACE (Adverse Childhood Experiences) Screening

Standardized Adverse Childhood Experiences (ACE) screening questionnaire assessing 10 categories of childhood adversity. Used to identify trauma history and inform trauma-informed care approaches.

2 pages•14 fields•HIPAA-ready
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Activities of Daily Living (ADL) Assessment Form
Patient Name
Date of Assessment
Bathing Independence
Dressing Independence
Toileting Independence
Transferring (Bed to Chair)
Continence Status
Feeding Independence
Submit
Screening

Activities of Daily Living (ADL) Assessment Form

Assess patient independence in activities of daily living (ADLs) and instrumental activities (IADLs) including bathing, dressing, mobility, meal preparation, and medication management.

2 pages•14 fields•HIPAA-ready
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AUDIT Alcohol Screening Form
Patient Name
Date of Screening
Drinking Frequency
Typical Drinks Per Session
Binge Drinking Frequency
Unable to Stop Drinking
Failed Expectations Due to Drinking
Morning Drinking
Submit
Screening

AUDIT Alcohol Screening Form

WHO Alcohol Use Disorders Identification Test (AUDIT) screening form to identify hazardous drinking, harmful alcohol use, and potential alcohol dependence in patients.

1 page•12 fields•HIPAA-ready
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Autism M-CHAT Screening Form
Child's Name
Date of Birth
Child's Age (months)
Parent/Guardian Name
Points to Show Interest
Interest in Other Children
Responds to Name
Makes Eye Contact
Submit
Screening

Autism M-CHAT Screening Form

Modified Checklist for Autism in Toddlers (M-CHAT) screening form for early detection of autism spectrum disorder in children aged 16 to 30 months.

2 pages•24 fields•HIPAA-ready
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Blood Pressure Log Form
Patient Name
Date and Time of Reading
Systolic Pressure (mmHg)
Diastolic Pressure (mmHg)
Heart Rate (bpm)
Measurement Arm
Select...
BP Classification
Select...
Symptoms or Notes
Submit
Screening

Blood Pressure Log Form

Structured blood pressure monitoring log for tracking systolic and diastolic readings, heart rate, and symptoms across multiple measurement sessions.

1 page•8 fields•HIPAA-ready
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BMI & Body Composition Form
Patient Name
Date of Measurement
Weight (lbs/kg)
Height (in/cm)
BMI recording
BMI Classification
Select...
Waist Circumference
Body Fat Percentage
Submit
Screening

BMI & Body Composition Form

BMI calculation and body composition tracking form for monitoring weight status, waist circumference, and body fat percentage across patient visits.

1 page•10 fields•HIPAA-ready
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CAGE Alcohol Screening Questionnaire
Patient Name
Date of Birth
Date of Screening
Have you felt you should Cut down on drinking?
Have people Annoyed you by criticizing your drinking?
Have you felt Guilty about your drinking?
Have you had a morning Eye-opener drink?
Current Drinking Frequency
Select...
Submit
Screening

CAGE Alcohol Screening Questionnaire

Classic four-question CAGE alcohol screening tool for rapid identification of potential alcohol use disorders. Simple, validated instrument widely used in primary care and emergency settings.

1 page•10 fields•HIPAA-ready
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Patient Name
Date of Injury
Mechanism of Injury
Loss of Consciousness
Amnesia Duration
Select...
Symptom Severity Checklist
Headache Severity (0-6)
Dizziness Severity (0-6)
Submit
Screening

Concussion SCAT Assessment Form

Sport Concussion Assessment Tool (SCAT) form for standardized sideline and clinical evaluation of suspected concussions following head injuries.

3 pages•20 fields•HIPAA-ready
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