Maine Patient Consent Form for Medical Treatment

MAINE PATIENT CONSENT FORM FOR MEDICAL TREATMENT

PROVIDER AND PATIENT INFORMATION

SECTION 1. PROPOSED TREATMENT, PROCEDURE OR SERVICE

I, the undersigned patient (or authorized representative), authorize the following provider(s) to perform the procedure(s)/treatment(s) described below:

• Treating physician / clinician: [____________________________]
• Procedure or treatment: [____________________________]
• Anatomic site (if applicable): [____________________________]
• Reason / clinical indication: [____________________________]
• Anticipated date of service: [__/__/____]

SECTION 2. INFORMATION DISCLOSED (24 M.R.S. § 2905)

The provider has explained, and I acknowledge that I have a general understanding of:

☐ The nature of my condition or diagnosis
☐ The nature and purpose of the proposed procedure or treatment
☐ The usual and most frequent risks and hazards inherent in the proposed procedure, including but not limited to:

• [____________________________]
• [____________________________]
• [____________________________]
  ☐ The probability of success based on my condition
  ☐ Reasonable alternatives, including non-treatment, and their risks and benefits
  ☐ Anticipated benefits and prognosis with and without treatment
  ☐ Anesthesia or sedation to be used (if applicable) and its risks
  ☐ Estimated recovery time and post-treatment instructions

SECTION 3. MATERIAL RISK ACKNOWLEDGMENT (Woolley v. Henderson)

I understand that no procedure is risk-free. The following material risks specific to my situation have been discussed with me:

• [____________________________]
• [____________________________]
• [____________________________]

I understand that unforeseen conditions may be discovered during the procedure that require additional or different treatment. I authorize my provider to perform such additional procedures as are reasonably necessary in their professional judgment.

☐ Yes, I authorize necessary additional procedures
☐ No, I do NOT authorize additional procedures except in life-threatening emergencies

SECTION 4. ANESTHESIA (IF APPLICABLE)

I have been informed of the type of anesthesia recommended, its risks (which may include reaction, respiratory or cardiac complications, or, rarely, death), and any alternatives.

Anesthesia provider: [____________________________]

SECTION 5. CAPACITY AND VOLUNTARINESS (18-C M.R.S. § 5-812)

Maine law presumes that an adult patient has capacity to make health care decisions. By signing, I confirm:

☐ I am at least 18 years of age (or qualify under 22 M.R.S. § 1502 / § 1503 / § 1908)
☐ I am mentally and physically competent to give consent (24 M.R.S. § 2905(1)(B))
☐ I am giving consent voluntarily, free of coercion or undue influence
☐ I have had an opportunity to ask questions, and my questions have been answered to my satisfaction
☐ I have been provided this form in a language I understand, with interpreter services if needed

Interpreter used: ☐ No ☐ Yes — Name/Service: [____________________________]

SECTION 6. MINOR CONSENT (Where Applicable)

Complete only if patient is under 18.

☐ Parent / legal guardian consent (default)
☐ Minor consents under 22 M.R.S. § 1502 — substance use disorder or emotional/psychological treatment
☐ Minor consents under 22 M.R.S. § 1503 — minor is/was married, in Armed Forces, emancipated, or living separately and independent of parental support
☐ Minor consents under 22 M.R.S. § 1908 — testing/treatment for sexually transmitted infection
☐ Emergency exception — delay would jeopardize health (24 M.R.S. § 2905(2))

Basis confirmed by: [____________________________] Date: [__/__/____]

SECTION 7. PHOTOGRAPHY, RECORDING, OBSERVERS

☐ I consent to clinical photography/recording for the medical record
☐ I consent to use of de-identified images for education/training
☐ I consent to observation by students, residents, or trainees
☐ I do NOT consent to any photography, recording, or non-essential observers

SECTION 8. PELVIC, RECTAL, OR PROSTATE EXAMINATIONS UNDER ANESTHESIA (24 M.R.S. § 2905-B)

I specifically authorize/decline pelvic, rectal, or prostate examinations performed while I am unconscious or anesthetized:

☐ I authorize such examinations only when medically necessary or directly related to the consented procedure
☐ I do NOT authorize such examinations except in a documented emergency
☐ Not applicable

SECTION 9. FINANCIAL RESPONSIBILITY

I acknowledge that I am financially responsible for charges not covered by insurance, and that no guarantee of outcome has been made.

SECTION 10. RIGHT TO REFUSE OR WITHDRAW

I understand I may refuse or withdraw consent at any time before the procedure begins, and that withdrawal will not affect my future care, except that the provider may decline to provide non-emergent services that the provider deems clinically inappropriate.

SECTION 11. ADVANCE DIRECTIVES

☐ I have an advance health care directive on file (18-C M.R.S. § 5-801 et seq.)
☐ I have designated a health care agent: [____________________________]
☐ I have not executed an advance directive
☐ Copy attached to this consent

SECTION 12. PATIENT / REPRESENTATIVE SIGNATURE

By signing below, I confirm that I have read (or had read to me) this form, that the disclosures in Section 2 were made to me, and that I voluntarily consent.

If signed by representative, basis of authority:
☐ Parent / Legal Guardian
☐ Health Care Agent under 18-C M.R.S. § 5-801 et seq.
☐ Surrogate under 22 M.R.S. § 1503-A
☐ Court-appointed guardian / conservator
☐ Other: [____________________________]

SECTION 13. PROVIDER ATTESTATION

I attest that I personally informed the patient (or representative) of the nature, risks, benefits, and reasonable alternatives to the proposed procedure in accordance with 24 M.R.S. § 2905 and prevailing standards of practice in this community, and that the patient demonstrated understanding and gave voluntary informed consent.

SECTION 14. WITNESS

SECTION 15. INTERPRETER ATTESTATION (If Used)

I am fluent in English and [__________] and accurately interpreted this form and the provider's disclosures for the patient.

SOURCES AND REFERENCES

• 24 M.R.S. § 2905 — Informed consent to health care treatment: https://legislature.maine.gov/statutes/24/title24sec2905-2.html
• 24 M.R.S. § 2905-B — Informed consent for pelvic, rectal or prostate examination: https://legislature.maine.gov/statutes/24/title24sec2905-B.html
• 18-C M.R.S. Article 5, Part 8 — Maine Uniform Health-Care Decisions Act: https://legislature.maine.gov/statutes/18-C/title18-Cch5sec0.html
• 18-C M.R.S. § 5-812 — Capacity (presumption): https://legislature.maine.gov/statutes/18-C/title18-Csec5-812.html
• 22 M.R.S. ch. 260 — Consent of Minors for Health Services: https://legislature.maine.gov/statutes/22/title22ch260.pdf
• Woolley v. Henderson, 418 A.2d 1123 (Me. 1980)
• Physician's Guide to Maine Law: https://www.mainemed.com/sites/default/files/content/PGML_2015Updated.pdf