Delaware Patient Informed Consent Form for Treatment

Delaware Patient Informed Consent Form for Treatment

I. Patient and Provider Identification

II. Proposed Treatment, Procedure, or Diagnostic Service

Description of proposed care: [________________________________________________]

Anatomical site (if applicable): [____________________________________]

Anticipated date(s) of service: [__/__/____] through [__/__/____]

Provider performing the service: [____________________________________]

Anesthesia type (if any):
☐ None ☐ Local ☐ Regional ☐ Monitored anesthesia care ☐ General ☐ Other: [__________]

III. Statutory Disclosure (18 Del. C. § 6852)

I acknowledge that my provider has discussed the following with me to a degree reasonably comprehensible to general lay understanding:

☐ The nature of the proposed treatment, procedure, or diagnosis.
☐ The purpose and intended benefits of the proposed care.
☐ The material risks, including those a reasonable patient in my position would consider significant.
☐ The reasonable alternatives to the proposed care, including non-treatment.
☐ The probable consequences of declining the proposed care.
☐ My right to ask questions and to withdraw consent at any time before the procedure begins.

IV. Specific Risks Disclosed

The following specific risks were disclosed and discussed:

1. [____________________________________]
2. [____________________________________]
3. [____________________________________]
4. [____________________________________]
5. [____________________________________]

Material risks may include (check all discussed):
☐ Bleeding ☐ Infection ☐ Adverse drug reaction ☐ Anesthesia complications
☐ Damage to adjacent structures ☐ Need for further procedures ☐ Scarring
☐ Loss of function ☐ Permanent disability ☐ Death (low probability)
☐ Other: [____________________________________]

V. Alternatives Considered

VI. Capacity Determination

☐ Patient is 18 years of age or older and appears to possess decision-making capacity.
☐ Patient is a minor; consent provided pursuant to 13 Del. C. § 707 by:
☐ Parent ☐ Legal guardian ☐ Relative caregiver (per § 707(b)) ☐ Married minor (self)
☐ Minor 18+ self-consenting ☐ Emancipated minor (court order attached)
☐ Patient lacks capacity; consent provided by health-care agent or surrogate pursuant to 16 Del. C. ch. 25:
☐ Agent under advance health-care directive ☐ Default surrogate per 16 Del. C. § 2507
☐ Court-appointed guardian (Order No. [__________])

VII. Minor-Specific Self-Consent (Where Applicable)

A minor may self-consent in Delaware for the following without parental involvement:

☐ Sexually transmitted disease examination/treatment — 16 Del. C. § 710 (any age).
☐ Pregnancy-related care — well-established under § 707 framework for minors.
☐ Voluntary substance-abuse treatment — 16 Del. C. § 2210:
☐ Minor under 14: parent/guardian consent required.
☐ Minor age 14+: minor may self-consent to non-residential treatment.
☐ Residential treatment: parent/guardian consent required regardless of age.
☐ Married minor or minor 18+ — full self-consent under 13 Del. C. § 707.
☐ Emancipated minor — by court order.

VIII. Emergency Exception

☐ This consent form is not required because emergency treatment is being rendered to a patient who is unable to consent and no surrogate is reasonably available; care is necessary to prevent serious harm or death (implied consent doctrine).

Documenting clinician: [____________________________________]
Time emergency began: [_____:_____ ☐ AM ☐ PM] on [__/__/____]

IX. Statutory Defenses Acknowledged

I understand and acknowledge:

☐ Hazards inherent in the proposed treatment that a person of ordinary intelligence in my position could reasonably appreciate.
☐ I am proceeding regardless of the disclosed risks and have had ample opportunity to ask questions.
☐ I waive no right to refuse, withdraw, or condition my consent.

X. Special Authorizations

☐ Photography / video / imaging for the medical record.
☐ Photography / video for educational or training purposes (de-identified).
☐ Tissue / specimen disposition in accordance with facility policy.
☐ Blood products administration, if medically indicated.
☐ Patient declines blood products: [____________________________________]
☐ Trainees / residents / students may participate under attending supervision.
☐ Implants / devices as medically indicated.

XI. Interpreter and Communication Aids

☐ Patient is fluent in English; no interpreter needed.
☐ Interpreter provided in [__________] language.
Interpreter Name: [____________________________] ID: [__________]
☐ Patient is hearing-impaired; ASL/CART services provided.
☐ Patient has cognitive limitations addressed by: [__________________________]

XII. Patient Acknowledgment and Signature

I have read or had read to me the contents of this form. My questions have been answered to my satisfaction. I voluntarily authorize the named provider and necessary assistants to perform the treatment described above.

XIII. Provider Attestation

I have personally discussed the proposed treatment with the patient (or authorized decision-maker), including the nature, purpose, material risks, reasonable alternatives, and probable consequences of refusal, in a manner consistent with the disclosure customarily given by Delaware-licensed providers in the same or similar field. I have answered all questions to the patient's apparent satisfaction.

XIV. Withdrawal of Consent

I understand consent may be withdrawn orally or in writing at any time before the procedure begins, and that withdrawal will not affect my right to alternative care.

Withdrawn on: [__/__/____] at [_____:_____ ☐ AM ☐ PM]
Patient signature: [____________________________________]
Witness: [____________________________________]

Sources and References

• 18 Del. C. § 6852 (Informed Consent in Medical Negligence Actions)
• 16 Del. C. ch. 25 (Uniform Health-Care Decisions Act)
• 13 Del. C. § 707 (Consent to Health Care of Minors)
• 16 Del. C. § 710 (Minor Consent — STDs)
• 16 Del. C. § 2210 (Substance Abuse — Voluntary Treatment Consent)
• Delaware Board of Medical Licensure and Discipline regulations, 24 DE Admin. Code 1700