Iowa Patient Consent Form - Treatment

IOWA PATIENT CONSENT TO TREATMENT

Provider Entity: [LEGAL NAME OF HOSPITAL / CLINIC / PHYSICIAN GROUP] ("Provider")
Treating Clinician: [NAME, M.D./D.O./N.P./P.A.] (Iowa License No. [______])
Patient: [LEGAL NAME] (DOB: [__/__/____])
Authorized Representative (if any): [NAME / RELATIONSHIP / AUTHORITY]
Date / Time of Disclosure: [__/__/____] at [__:__] [AM/PM]
Facility / Location: [ADDRESS, CITY, COUNTY, IOWA]
Governing Law: State of Iowa

I. DISCLOSURE OF NATURE AND PURPOSE OF PROCEDURE

In compliance with Iowa Code § 147.137(1)(a), the Patient (or Representative) acknowledges receipt of the following disclosure:

II. MATERIAL RISKS DISCLOSED (Iowa Code § 147.137(1)(a); Pauscher v. Iowa Methodist Med. Ctr.)

The Patient has been informed of the following risks specifically enumerated by Iowa Code § 147.137 where reasonably determinable, together with such additional risks as a reasonable person in the Patient's position would consider material to the decision to undergo treatment:

Additional procedure-specific risks disclosed: [LIST — e.g., infection, hemorrhage, allergic reaction, anesthesia complications, need for further surgery, device failure, etc.]

III. ALTERNATIVES AND CONSEQUENCES OF NON-TREATMENT

IV. ACKNOWLEDGMENTS REQUIRED BY IOWA CODE § 147.137(1)(b)

By signing below, the Patient (or Representative) acknowledges:

• ☐ The disclosures set forth in Sections I–III have been made.
• ☐ All questions concerning the procedure(s) have been answered to the Patient's satisfaction.
• ☐ The Patient has had a reasonable opportunity to consider the information before signing.
• ☐ The Patient understands medicine is not an exact science and no specific result has been guaranteed.
• ☐ The Patient consents to the administration of any anesthesia deemed advisable by the anesthesia provider.
• ☐ The Patient consents to disposal of removed tissue/specimens consistent with applicable law and Provider policy.
• ☐ The Patient authorizes performance of additional or different procedures only if necessary to address an unforeseen condition discovered during treatment that, in the clinician's professional judgment, requires immediate action.

V. CAPACITY, REPRESENTATIVES, AND ADVANCE DIRECTIVES

A. Adult Capacity

The Patient represents that [he/she/they] is an adult (≥18, Iowa Code § 599.1) with capacity to consent. If the Patient lacks capacity, signature is provided under one of the following authorities:

• ☐ Durable Power of Attorney for Health Care (Iowa Code ch. 144B). Attach copy.
• ☐ Court-appointed guardian (Iowa Code ch. 633). Attach order.
• ☐ Surrogate decision-maker under Provider policy/Iowa law. Document basis: [______]
• ☐ Declaration relating to life-sustaining procedures (Iowa Code ch. 144A). Attach copy.

B. Minor Patient (under 18)

☐ Consent provided by parent/legal guardian: [NAME / RELATIONSHIP]
☐ Minor consenting personally under a statutory exception:
    ☐ HIV/STD screening or treatment — Iowa Code § 141A.7(3)
    ☐ Substance use disorder treatment — Iowa Code § 125.33
    ☐ Emancipated minor (court order attached)
    ☐ Other statutory authority: [CITE — verify currency before use]

C. Advance Directives

The Patient affirms ☐ has ☐ does not have an advance directive on file. If yes, type: ☐ Living Will (ch. 144A) ☐ Durable POA-HC (ch. 144B) ☐ POLST/Out-of-Hospital DNR.

VI. PHOTOGRAPHY, RECORDING, AND TRAINEE PARTICIPATION

• ☐ Patient consents to clinical photography/recording for the medical record.
• ☐ Patient consents to participation by residents, students, and other trainees under attending supervision.
• ☐ Patient consents to use of de-identified images/data for educational or quality-improvement purposes.

VII. PRIVACY ACKNOWLEDGMENT

The Patient acknowledges receipt of Provider's Notice of Privacy Practices under HIPAA (45 C.F.R. § 164.520) and understands protected health information may be used and disclosed for treatment, payment, and health care operations consistent with state and federal law.

VIII. RIGHT TO REFUSE OR WITHDRAW CONSENT

The Patient may refuse any treatment or withdraw this consent at any time before the procedure begins, subject to consequences disclosed in Section III.

Patient initials confirming right to refuse/withdraw: [____]

IX. CLINICIAN ATTESTATION

I, the undersigned clinician, attest that I personally disclosed to the Patient (or Representative) the nature, purpose, material risks, alternatives, and consequences of non-treatment described above; answered all questions; assessed capacity; and obtained voluntary consent.

X. PATIENT / REPRESENTATIVE SIGNATURE

XI. STATUTORY NOTE

A consent meeting all elements of Iowa Code § 147.137(1) creates a rebuttable presumption that informed consent was given. The presumption may be overcome by evidence that the disclosure was inaccurate, the patient lacked capacity, signature was procured by duress or fraud, or material risk-information required by the reasonable-patient standard articulated in Pauscher v. Iowa Methodist Medical Center, 408 N.W.2d 355 (Iowa 1987), was withheld.