PATIENT CONSENT FOR TREATMENT
(Georgia – Comprehensive Informed Consent Form)
[// GUIDANCE: Replace every bracketed placeholder before use. Delete all GUIDANCE comments prior to final execution.]
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
1.1 Title and Parties
This Patient Consent for Treatment (the “Consent”) is entered into and made effective as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
(a) [PATIENT LEGAL NAME], residing at [PATIENT ADDRESS] (“Patient”); and
(b) [PROVIDER LEGAL NAME], a [STATE OF FORMATION] [ENTITY TYPE] doing business as [DBA, if any], with its principal place of business at [ADDRESS] (“Provider”).
1.2 Recitals
A. Provider has explained that Patient’s diagnosis and condition require or may benefit from the medical treatment, procedure(s), and/or course of care described herein (collectively, the “Treatment”).
B. Patient desires to voluntarily provide informed consent to such Treatment in accordance with Georgia’s informed consent statute, O.C.G.A. § 31-9-6, and applicable federal law.
C. In consideration of the mutual promises and covenants herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows.
2. DEFINITIONS
For purposes of this Consent, the following terms have the meanings set forth below. Terms capitalized but not defined shall have the meanings assigned elsewhere in this Consent.
“Authorized Representative” – An individual legally empowered to consent on behalf of the Patient under O.C.G.A. § 31-9-2.
“Capacity” – The ability to understand the nature and consequences of the proposed Treatment and to make a knowing and voluntary decision.
“Disclosure” – The information required to be provided to the Patient under Section 3.1.
“Emergency” – A condition meeting the criteria of O.C.G.A. § 31-9-3 permitting treatment without prior consent.
“Protected Health Information” or “PHI” – Has the meaning set forth in 45 C.F.R. § 160.103.
“Treatment” – The specific medical procedure(s), therapy, or course of care described in Section 3.2, as may be modified pursuant to Section 5.1.
3. OPERATIVE PROVISIONS
3.1 Required Disclosures
Provider has, in compliance with O.C.G.A. § 31-9-6, provided Patient with information in a manner reasonably understood by Patient, including:
a. Diagnosis and nature of Patient’s condition;
b. Name and description of the proposed Treatment;
c. Material risks and reasonably foreseeable complications, including but not limited to [INSERT MATERIAL RISKS];
d. Probability of success and expected outcome;
e. Viable alternative treatments and associated risks;
f. Likely result of no treatment; and
g. Identity, credentials, and professional status of Provider and materially participating personnel.
3.2 Description of Treatment
The Treatment for which consent is sought is:
• [DESCRIPTION OF PROCEDURE(S)]
• [ANCILLARY SERVICES]
• [SEDATION/ANESTHESIA DETAILS, if applicable].
3.3 Voluntary Consent
a. Patient affirms having the Capacity to consent.
b. Patient confirms opportunity to ask questions and that all questions have been answered to Patient’s satisfaction.
c. Patient understands the right to refuse or withdraw consent at any time prior to commencement or continuation of Treatment, subject to Section 6.
3.4 Consideration
No separate monetary consideration is exchanged for this Consent; however, Provider’s agreement to render Treatment constitutes good and valuable consideration under applicable law.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider Representations
a. Provider is duly licensed and in good standing to practice medicine in the State of Georgia.
b. Provider holds professional liability insurance in compliance with O.C.G.A. § 43-34-47.
c. Provider has disclosed any financial or ownership interests relevant to the Treatment.
4.2 Patient Representations
a. Patient has provided accurate medical history, including allergies, medications, and prior conditions.
b. Patient is not relying on any statements not contained herein or in the accompanying Disclosure materials.
c. If an Authorized Representative executes this Consent, such representative warrants legal authority to act.
4.3 Survival
Representations and warranties survive completion of Treatment to the extent necessary for enforcement under Section 6.
5. COVENANTS & RESTRICTIONS
5.1 Modification of Treatment
Provider may adjust the Treatment intra-operatively or during care when, in Provider’s professional judgment, such modification is in Patient’s best medical interest and materially consistent with the objectives. Provider will endeavor to obtain contemporaneous consent where feasible.
5.2 Compliance with Instructions
Patient shall follow pre-operative and post-operative instructions furnished by Provider. Failure may increase risks and limit Provider’s liability as set forth in Section 7.
5.3 Notice of Change in Condition
Patient agrees to notify Provider promptly of any unexpected or adverse developments.
6. DEFAULT & REMEDIES
6.1 Withdrawal of Consent
Patient may revoke this Consent at any time by written or verbal notice. If Treatment is in progress, Provider will safely terminate when medically practicable.
6.2 Provider Right to Suspend
Provider may refuse or suspend Treatment if:
a. Patient revokes consent;
b. Patient fails to comply with Section 5.2; or
c. Provider determines continuation poses unreasonable risk.
6.3 Remedies
• Neither party waives any remedy available at law or equity, provided that remedies shall be limited as stated in Section 7.
• Patient remains responsible for fees incurred up to the point of revocation or suspension.
7. RISK ALLOCATION
7.1 Indemnification – Informed Consent Protection
Patient shall indemnify and hold harmless Provider and its personnel from claims, damages, and expenses arising out of Patient’s material misrepresentations or failure to disclose medical information, except to the extent caused by Provider’s negligence or willful misconduct.
7.2 Limitation of Liability
To the fullest extent permitted by Georgia law, Provider’s aggregate liability for non-economic damages arising from the Treatment shall not exceed any statutory caps applicable to medical malpractice actions at the time of judgment; provided, however, nothing herein shall be construed to:
a. Waive or limit Patient’s right to bring a malpractice action under O.C.G.A. § 9-3-71 et seq.; or
b. Contravene any Georgia Supreme Court ruling invalidating statutory caps.
[// GUIDANCE: Currently, Georgia’s non-economic damages cap has been held unconstitutional. Retain clause to the extent future law permits.]
7.3 Insurance
Patient acknowledges Provider maintains professional liability coverage meeting or exceeding state minimums.
7.4 Force Majeure
Neither party is liable for delays or failure to perform resulting from acts beyond reasonable control, excluding payment obligations already incurred.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Consent and any dispute hereunder shall be governed by the substantive medical and contract law of the State of Georgia, without regard to conflict-of-law rules.
8.2 Forum Selection
Exclusive venue shall lie in the state courts located in [COUNTY], Georgia.
8.3 Arbitration (Optional)
[SELECT ONE]
☐ Arbitration Elected – Any dispute shall be resolved by binding arbitration in accordance with the American Arbitration Association’s Healthcare Rules. Judgment on the award may be entered in any court of competent jurisdiction.
☐ Arbitration Declined – Disputes shall be resolved exclusively in the courts designated in Section 8.2.
8.4 Jury Trial
Nothing herein constitutes a waiver of the constitutional right to a jury trial. If arbitration is elected, the jury trial right is waived only for arbitrable claims.
8.5 Injunctive Relief
The parties agree that injunctive relief shall be limited to circumstances where immediate medical harm is likely absent court intervention.
9. GENERAL PROVISIONS
9.1 Amendments and Waivers
Any amendment must be in writing and signed by both parties. No waiver is effective unless in writing and signed by the party waiving.
9.2 Assignment
Neither party may assign or delegate its rights or obligations without prior written consent, except that Provider may assign to an affiliated practice entity by operation of law.
9.3 Entire Agreement
This Consent, together with all Disclosure materials delivered concurrently herewith, constitutes the entire agreement regarding the subject matter and supersedes all prior oral or written communications.
9.4 Severability
If any provision is held invalid, the remaining provisions shall remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to comply with applicable law.
9.5 Counterparts; Electronic Signatures
This Consent may be executed in counterparts, each of which constitutes an original and all of which constitute one agreement. Electronic and facsimile signatures are deemed original for all purposes.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Consent effective as of the Effective Date.
PATIENT:
[PRINT PATIENT NAME]
Signature: ______
Date: __________
IF APPLICABLE – AUTHORIZED REPRESENTATIVE:
I represent that I am legally authorized under O.C.G.A. § 31-9-2 to consent on behalf of Patient.
[PRINT REPRESENTATIVE NAME & RELATIONSHIP]
Signature: ______
Date: __________
PROVIDER:
[PRINT PROVIDER NAME & TITLE]
Signature: ______
Date: __________
WITNESS (optional/recommended):
[PRINT WITNESS NAME]
Signature: ______
Date: __________
NOTARY (if required):
State of Georgia County of __
Subscribed and sworn before me on this ___ day of ____, 20__.
Notary Public
My Commission Expires: ____
[// GUIDANCE:
1. Attach detailed risk sheets or procedure-specific supplements as needed.
2. Retain executed original in Patient’s medical record.
3. Update to reflect changes in Georgia informed consent law or facility policies.]