TREATMENT CONSENT FORM
State of Connecticut
[// GUIDANCE: This template is drafted to satisfy Connecticut’s informed-consent doctrine, disclosure obligations under state medical‐law standards, and capacity requirements under the Connecticut Health Care Decisions framework. All bracketed fields must be customized by counsel or clinical staff prior to use.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
Treatment Consent Form (“Agreement”)
Effective Date: [DATE]
Parties:
a. Patient: [LEGAL NAME], DOB [MM/DD/YYYY], Address [ADDRESS] (“Patient”).
b. Legal Representative (if applicable): [NAME / CAPACITY] (“Representative”).
c. Treating Provider: [PHYSICIAN / ADVANCED PRACTICE PROVIDER LEGAL NAME], CT License No. [NUMBER] (“Provider”).
d. Facility: [HOSPITAL / CLINIC LEGAL NAME], located at [ADDRESS] (“Facility”).
Recitals
A. Patient (or Representative) seeks to obtain certain medical, surgical, or diagnostic services from Provider at Facility (collectively, the “Treatment”).
B. Provider is willing to render the Treatment subject to Patient’s informed consent in accordance with the laws of the State of Connecticut (“Governing Law”).
C. The parties therefore enter into this Agreement to memorialize their rights, duties, and obligations concerning the Treatment.
2. DEFINITIONS
For purposes of this Agreement, the following terms have the meanings set forth below. Capitalized terms not defined in this Section have the meanings ascribed elsewhere in the Agreement.
“Agreement” has the meaning given in the Document Header.
“Arbitration Election” means the Patient’s indication in Section 8.3 as to whether any Dispute will be submitted to binding arbitration.
“Dispute” means any claim, controversy, or disagreement arising out of or relating to this Agreement or the Treatment.
“Emergency” means a sudden, unexpected medical condition requiring immediate action where delay would endanger the Patient’s health or life.
“Malpractice Limits” means any non-waivable limits on liability imposed under Connecticut law with respect to professional negligence claims.
“Material Risk” means a risk that a reasonable person in the Patient’s position would consider significant in deciding whether to consent to the Treatment.
“Protected Health Information” or “PHI” has the meaning assigned under 45 C.F.R. § 160.103.
“Representative” has the meaning set forth in the Document Header.
“Treatment” has the meaning set forth in the Recitals.
3. OPERATIVE PROVISIONS
3.1 Consent to Treatment
a. Patient hereby voluntarily consents to the Treatment, including all customary diagnostic tests, imaging, laboratory work, pharmacological therapy, nursing services, and medically appropriate ancillary procedures.
b. Consent extends to any additional or alternative procedures deemed medically necessary during the course of Treatment, provided such procedures are consistent with Patient’s wishes and the Governing Law.
3.2 Description of Proposed Treatment
Provider has explained, in language understandable to Patient, the nature, purpose, intended benefits, and anticipated course of the Treatment, including the identity and roles of all materially involved clinicians.
[PLACEHOLDER – INSERT PROCEDURE-SPECIFIC DESCRIPTION]
3.3 Disclosure of Material Risks and Complications
Provider has disclosed the Material Risks associated with the Treatment, including but not limited to:
• [PLACEHOLDER – RISK 1]
• [PLACEHOLDER – RISK 2]
• [PLACEHOLDER – RISK 3]
Patient acknowledges understanding that unforeseen complications may arise.
3.4 Alternatives, Including No Treatment
Provider has described reasonable medically acceptable alternatives, including potential outcomes of foregoing Treatment. Patient affirms that all questions concerning alternatives have been answered to Patient’s satisfaction.
3.5 Capacity and Surrogate Decision-Making
a. Patient affirms being at least 18 years of age and possessing decisional capacity under Connecticut law OR is represented by a legally authorized Representative.
b. Representative warrants authority to consent pursuant to an applicable advance directive, power of attorney for health care, guardianship, or statutory priority scheme.
3.6 Authorization for Sedation and/or Anesthesia
Where applicable, Patient consents to the administration of local, regional, or general anesthesia and acknowledges having discussed associated risks with the anesthesia professional.
[PLACEHOLDER – ANESTHESIA PROVIDER NAME & CREDENTIALS]
3.7 Blood Products
Patient (i) consents / (ii) refuses [SELECT ONE] the administration of blood or blood products and understands potential consequences of refusal.
[// GUIDANCE: If Patient refuses, Provider should secure a separate Jehovah’s Witness or similar blood refusal form.]
3.8 Right to Withdraw or Withhold Consent
Patient may revoke consent at any time prior to Treatment commencement, or refuse any particular procedure, without prejudice to future care or access to services, except as may be medically contraindicated in an Emergency.
3.9 HIPAA Authorization (Limited)
Patient authorizes Provider to use and disclose PHI for purposes of treatment, payment, and health-care operations consistent with the Notice of Privacy Practices previously provided.
3.10 Financial Responsibility
Patient accepts financial responsibility for all charges not covered by insurance and agrees to pay amounts owed within [30] days of invoice.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider
a. Provider is duly licensed and in good standing under Connecticut law.
b. Provider has obtained all required approvals, credentials, and professional liability insurance.
4.2 Patient / Representative
a. All personal and medical information provided is complete and accurate to the best of Patient’s knowledge.
b. Patient acknowledges receipt of: (i) Provider’s Notice of Privacy Practices; (ii) Facility’s Patient Bill of Rights; and (iii) an opportunity to ask questions.
4.3 Survival
The representations and warranties in this Section survive completion of Treatment to the extent necessary to resolve any Dispute.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants
a. To follow pre- and post-Treatment instructions.
b. To notify Provider promptly of any adverse change in condition.
5.2 Provider Covenants
To exercise the degree of care, skill, and diligence required of reasonably prudent health-care providers in Connecticut.
5.3 No Guarantee of Results
Provider makes no guarantee, promise, or warranty as to the success or ultimate outcome of the Treatment.
6. DEFAULT & REMEDIES
6.1 Payment Default
If Patient fails to pay amounts due within the specified timeframe, Facility may (i) assess interest at [1.0 %] per month, and (ii) pursue collection consistent with applicable law.
6.2 Provider Right to Decline or Discontinue Treatment
Provider may decline or discontinue non-emergent Treatment for (i) nonpayment, (ii) Patient’s material breach of this Agreement, or (iii) ethical or professional grounds, subject to reasonable notice and an opportunity to secure alternative care.
6.3 Attorney’s Fees
In a collection action, the prevailing party is entitled to reasonable attorney’s fees and costs.
7. RISK ALLOCATION
7.1 Patient Indemnification
Patient agrees to defend, indemnify, and hold harmless Provider and Facility from any loss, liability, or expense arising out of inaccurate or omitted information supplied by Patient or Representative, except to the extent caused by Provider’s negligence or willful misconduct.
7.2 Limitation of Liability
Nothing in this Agreement limits liability for professional negligence beyond any Malpractice Limits imposed by Connecticut law.
7.3 Insurance
Provider maintains professional liability coverage in at least the minimum amount required under Connecticut law. Patient is encouraged to maintain adequate health-insurance coverage.
7.4 Force Majeure
Provider shall not be liable for delays or inability to perform caused by events beyond reasonable control, including natural disasters, pandemics, or governmental actions.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Agreement is governed by the substantive laws of the State of Connecticut (“state_medical_law”), without regard to conflict-of-laws rules.
8.2 Forum Selection
The parties submit to the exclusive jurisdiction of the Connecticut state courts located in [COUNTY] (“state_court”) for any Dispute not resolved under Section 8.3.
8.3 Optional Arbitration
☐ Patient ELECTS / ☐ Patient DECLINES binding arbitration.
[// GUIDANCE: If arbitration is elected, insert a detailed arbitration clause compliant with the Federal Arbitration Act and Connecticut Arbitration Statute.]
8.4 Jury Trial Waiver
To the fullest extent permitted by the Connecticut Constitution and applicable law, the parties knowingly and voluntarily waive the right to trial by jury in any Dispute.
8.5 Injunctive Relief
Nothing herein limits a party’s right to seek temporary or preliminary injunctive relief to preserve the status quo or prevent irreparable harm, subject to Section 7.2.
9. GENERAL PROVISIONS
9.1 Entire Agreement
This Agreement, together with any attachments identified below, constitutes the entire understanding regarding its subject matter and supersedes all prior oral or written communications.
9.2 Amendment and Waiver
No amendment or waiver is effective unless in writing and signed by both Patient (or Representative) and Provider. A waiver on one occasion is not a waiver of any subsequent breach.
9.3 Assignment
Neither party may assign this Agreement without the prior written consent of the other, except that Provider may assign to an entity owned or controlled by Provider.
9.4 Severability
If any provision is held invalid or unenforceable, the remaining provisions remain in full force, and the invalid provision is deemed modified to the minimum extent necessary to render it valid.
9.5 Notices
All notices must be in writing and delivered (i) in person; (ii) by certified mail, return receipt requested; or (iii) by nationally recognized overnight courier, to the addresses listed above.
9.6 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, each of which is deemed an original. Signatures may be exchanged by facsimile, PDF, or electronic signature platform and are binding.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Treatment Consent Form as of the Effective Date.
Patient / Representative
Signature: _____
Name: [PRINT]
Capacity (if Representative): [POA / Guardian / Parent]
Date: _____
Treating Provider
Signature: _____
Name: [PRINT]
Title / Credential: [M.D. / APRN / PA-C]
Date: _____
Facility Witness (optional under CT law)
Signature: _____
Name & Title: [PRINT]
Date: _____
[// GUIDANCE: Notarization is not customarily required for treatment consents in Connecticut. If the Facility’s policy mandates a witness or notary, insert the appropriate acknowledgment block here.]
Attachments (check all that apply):
☐ Procedure-Specific Risk Sheet
☐ Anesthesia Consent
☐ HIPAA Notice of Privacy Practices (acknowledged separately)
☐ Financial Responsibility Agreement
☐ Advance Directive / Living Will on file