Minnesota Patient Consent Form - Treatment

DISCLAIMER (MANDATORY — DO NOT DELETE)
This document is a model template for educational purposes only and does not constitute legal or medical advice. Minnesota's informed consent doctrine is largely judge-made (the "reasonable patient" standard articulated in Reinhardt v. Colton and Madsen v. Park Nicollet Medical Center), and statutory patient rights are continuously updated. A qualified Minnesota-licensed attorney and the treating clinician must review and customize this form before clinical use.

MINNESOTA PATIENT CONSENT TO TREATMENT

Effective Date: [__/__/____]
Provider Entity: [LEGAL NAME OF HOSPITAL / CLINIC / PHYSICIAN GROUP] ("Provider")
Treating Clinician: [NAME, CREDENTIAL, MN LICENSE NO.]
Patient: [LEGAL NAME] ("Patient")
Authorized Representative (if any): [NAME & RELATIONSHIP]
Governing Law: State of Minnesota

I. PURPOSE AND LEGAL FRAMEWORK

This form documents the Patient's informed consent to medical treatment in accordance with:

• The reasonable patient standard under Reinhardt v. Colton, 337 N.W.2d 88 (Minn. 1983), and Madsen v. Park Nicollet Med. Ctr., 431 N.W.2d 855 (Minn. 1988), which require disclosure of information that a reasonable person in the Patient's position would consider material to the decision whether to undergo treatment;
• The Minnesota Patients' Bill of Rights, Minn. Stat. § 144.651, including subdivision 9 (information about treatment), subdivision 11 (consultation), and subdivision 12 (right to refuse treatment);
• The Minnesota Health Care Directives Act, Minn. Stat. ch. 145C, governing capacity, surrogate decision-making, and advance directives; and
• Applicable minor-consent statutes: Minn. Stat. §§ 144.341, 144.343, 144.344, and 144.345.

II. DEFINITIONS

III. PATIENT INFORMATION

IV. PROPOSED TREATMENT / PROCEDURE

Diagnosis or Indication: [____________________________]

Proposed Treatment / Procedure: [____________________________]

Anatomical Site / Laterality (if applicable): [____________________________]

Anticipated Date of Procedure: [__/__/____]

Treating Clinician(s): [____________________________]

V. DISCLOSURE TO PATIENT (REASONABLE PATIENT STANDARD)

The Provider has explained, and the Patient acknowledges receipt of, the following information in language the Patient understands:

☐ Nature and purpose of the proposed treatment or procedure
☐ Reasonably foreseeable material risks, including (without limitation):

• [____________________________]
• [____________________________]
• [____________________________]
  ☐ Anticipated benefits and probability of success
  ☐ Reasonable alternatives, including non-treatment, and the risks and benefits of each
  ☐ Consequences of refusing or delaying treatment
  ☐ Anesthesia / sedation plan and associated risks (if applicable)
  ☐ Use of blood products / transfusion (if applicable)
  ☐ Identity of providers who will perform or participate in the procedure
  ☐ Possibility of unforeseen conditions requiring extended or different treatment

VI. PATIENT QUESTIONS AND RESPONSES

The Patient was given the opportunity to ask questions. Questions asked and answers provided:

☐ Patient confirms all questions have been answered to Patient's satisfaction.

VII. CAPACITY ASSESSMENT

☐ The Patient appears to have decisional capacity under Minn. Stat. ch. 145C.
☐ The Patient does not have capacity. Consent is being obtained from an authorized surrogate (see Section VIII).

Basis for capacity determination: [____________________________]

VIII. SURROGATE / REPRESENTATIVE CONSENT (if applicable)

IX. MINOR PATIENT CONSENT (Minn. Stat. §§ 144.341–144.345)

If the Patient is under 18, indicate basis for consent:

☐ Parent / legal guardian consent (default rule)
☐ Minn. Stat. § 144.341 — Minor living separate from parents, managing own financial affairs
☐ Minn. Stat. § 144.342 — Minor who is married or has borne a child
☐ Minn. Stat. § 144.343 — Pregnancy, contraception, or abortion services (minor may consent)
☐ Minn. Stat. § 144.344 — Diagnosis/treatment of sexually transmitted disease, alcoholism, or drug abuse
☐ Minn. Stat. § 144.345 — Emergency treatment where parent/guardian is unavailable

X. EMERGENCY TREATMENT EXCEPTION (Minn. Stat. § 144.345)

In a true emergency where consent cannot be obtained and delay would seriously endanger life or health, treatment may proceed without prior written consent. The clinician must document:

• Nature of the emergency: [____________________________]
• Reason consent could not be obtained: [____________________________]
• Treatment provided: [____________________________]
• Time / date: [__/__/____] [__:__]

XI. PATIENT RIGHTS UNDER MINN. STAT. § 144.651

The Patient has been informed of and understands the rights enumerated in the Minnesota Patients' Bill of Rights, including:

☐ Right to information about treatment (subd. 9)
☐ Right to participate in treatment planning (subd. 10)
☐ Right to consultation with another clinician (subd. 11)
☐ Right to refuse treatment and to be informed of medical consequences of refusal (subd. 12)
☐ Right to continuity of care (subd. 17)
☐ Right to confidentiality of medical records (subd. 16)
☐ Right to freedom from maltreatment (subd. 14)

XII. PHOTOGRAPHY, RECORDING, OBSERVERS, AND TRAINEES

☐ Patient consents to photography/video for medical record purposes only.
☐ Patient consents to presence of trainees / students under supervision.
☐ Patient does not consent to non-essential observers.

XIII. FINANCIAL DISCLOSURE

☐ Patient has been provided with available cost estimates and insurance information.
☐ Patient understands that out-of-network or non-covered services may result in additional charges.

XIV. PATIENT ATTESTATION

By signing below, the Patient (or authorized Representative) certifies:

1. The Patient has read or had this form read aloud and understands its contents;
2. The risks, benefits, and alternatives have been explained in terms the Patient understands;
3. All questions have been answered to the Patient's satisfaction;
4. The Patient consents voluntarily, free from coercion;
5. The Patient understands the right to withdraw consent at any time before the procedure begins.

XV. SIGNATURES

XVI. WITHDRAWAL OF CONSENT

The Patient may withdraw consent in writing at any time before the procedure begins. Withdrawal will not prejudice the Patient's right to other care.

Withdrawal received: ☐ Yes — Date: [__/__/____] ☐ No

XVII. CLINICIAN ATTESTATION

I certify that I have personally explained the nature, purpose, material risks, benefits, and reasonable alternatives of the proposed treatment to the Patient (or authorized Representative); that I have answered all questions; and that, in my professional judgment, the Patient (or Representative) has the capacity to provide informed consent under Minnesota law.

Clinician Signature: [____________] Date: [__/__/____]
MN License No.: [____________]

SOURCES AND REFERENCES

• Reinhardt v. Colton, 337 N.W.2d 88 (Minn. 1983) — reasonable patient standard
• Madsen v. Park Nicollet Med. Ctr., 431 N.W.2d 855 (Minn. 1988) — application to specific procedures
• Cornfeldt v. Tongen, 262 N.W.2d 684 (Minn. 1977) — origin of negligent nondisclosure cause of action
• Minn. Stat. § 144.651 — Health Care Bill of Rights
• Minn. Stat. ch. 145C — Health Care Directives Act
• Minn. Stat. §§ 144.341–144.345 — Minor consent statutes
• Minnesota Department of Health — Patients' Bill of Rights guidance