Patient Consent Form - Treatment

DISCLAIMER (MANDATORY — DO NOT DELETE)
The following document is a model template for educational purposes only and does not constitute legal or medical advice. Use of this template does not create an attorney-client or physician-patient relationship. North Dakota and federal requirements governing informed consent, decisional capacity, minor consent, and protected health information are complex and frequently updated; a qualified North Dakota-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT AGREEMENT

(North Dakota — Comprehensive Informed Consent Form)

I. PURPOSE AND ACKNOWLEDGMENT

A. Purpose. This Agreement documents the informed consent of Patient (or Representative) to one or more medical treatments, procedures, diagnostic studies, anesthesia services, or related care (collectively, "Treatment") to be furnished by Provider, in compliance with the North Dakota informed-consent doctrine as articulated in Jaskoviak v. Gruver, 2002 ND 1, 638 N.W.2d 1, and applicable federal law.

B. Reasonable-Patient / Materiality Standard. Patient acknowledges that under North Dakota law, a physician must disclose those risks, benefits, and alternatives that a reasonable patient in Patient's position would consider material to the decision whether to undergo Treatment.

C. Acknowledgment of Receipt. Patient acknowledges receipt of this Agreement and that its provisions have been explained in language Patient understands. A copy will be furnished upon request.

II. DEFINITIONS

"Adverse Event" — any unanticipated injury, complication, or outcome arising from Treatment requiring further intervention.

"Capacity" — Patient's ability to understand the nature, risks, benefits, and reasonable alternatives of Treatment and to make and communicate a decision; assessed consistent with NDCC ch. 23-06.5 and accepted clinical standards.

"Emergency Condition" — a condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function, permitting Treatment without express consent under recognized common-law emergency doctrine.

"Protected Health Information (PHI)" — individually identifiable health information protected under 45 C.F.R. Part 164 and applicable North Dakota confidentiality law.

"Surrogate / Agent" — a person authorized to make health-care decisions for Patient under a Health Care Directive executed pursuant to NDCC ch. 23-06.5 or applicable guardianship order.

III. SCOPE OF TREATMENT CONSENTED TO

A. Description of Treatment. Patient consents to the following Treatment:
[DESCRIBE PROCEDURE / COURSE OF CARE IN PLAIN LANGUAGE — anatomical site, route, anticipated duration]

B. Indication. Treatment is recommended for the following clinical indication:
[DIAGNOSIS / INDICATION]

C. Anticipated Benefits.
☐ [Specify expected therapeutic benefit]
☐ [Specify expected diagnostic benefit]
☐ Other: [________________________________]

D. Material Risks Disclosed. Patient has been advised of the following material risks, which a reasonable patient would consider relevant under Jaskoviak v. Gruver:
☐ Bleeding, infection, or adverse reaction to anesthesia
☐ Damage to adjacent tissues, organs, or nerves
☐ Failure of Treatment to achieve intended result
☐ Need for additional procedures, hospitalization, or transfusion
☐ Death or serious permanent disability (where clinically applicable)
☐ Procedure-specific risks: [________________________________]

E. Reasonable Alternatives Discussed.
☐ No treatment / watchful waiting and likely consequences
☐ Alternative medical management: [____________________]
☐ Alternative surgical or procedural approach: [____________________]
☐ Referral to specialist or second opinion

F. Questions Answered. Patient confirms that all questions have been answered to Patient's satisfaction. ☐ Yes ☐ No

IV. CAPACITY AND SURROGATE DECISION-MAKING

A. Capacity Determination. The treating clinician has assessed and documented Patient's Capacity. If Patient lacks Capacity, consent shall be obtained from a person with authority to act in the following order:

B. Health Care Directive. Patient ☐ has ☐ has not executed a Health Care Directive pursuant to NDCC ch. 23-06.5. A copy is ☐ attached ☐ on file ☐ requested.

C. Reservation of Rights. Patient (or Representative) may revoke this consent in writing or orally at any time before Treatment is performed, subject to limitations imposed by the clinical circumstances.

V. MINOR PATIENTS (NDCC ch. 14-10)

A. Age of Majority. Under NDCC § 14-10-01, the age of majority in North Dakota is eighteen (18) years.

B. Parental / Guardian Consent. For a minor Patient, consent is provided by:
☐ Parent or legal guardian: [NAME / RELATIONSHIP]
☐ Court-appointed guardian (order on file)

C. Minor Self-Consent Exceptions. A minor may consent to Treatment in the following recognized circumstances:
☐ Emergency Condition (delay would jeopardize life or health)
☐ Lawfully married minor
☐ Emancipated minor (court order or operation of law)
☐ Minor who is a parent consenting on behalf of own child
☐ Treatment for sexually transmitted disease (NDCC § 14-10-17)
☐ Other statutory exception: [________________________________]

D. Mature-Minor Documentation. Clinician has assessed and documented the minor's understanding of the Treatment and reasonable alternatives.

VI. ANESTHESIA, BLOOD PRODUCTS, AND SPECIMENS

A. Anesthesia. Patient consents to administration of anesthesia of the type and route deemed clinically appropriate, and acknowledges the material risks separately disclosed by the anesthesia provider.

B. Blood and Blood Products. Patient ☐ consents ☐ declines to receive blood and blood products if medically indicated. Religious or personal objections, if any: [____________________]

C. Tissue and Specimens. Patient ☐ consents ☐ does not consent to the retention, examination, and lawful disposition of tissues, fluids, and specimens removed during Treatment.

D. Photography / Recording. Patient ☐ consents ☐ does not consent to clinical photography or recording for medical-record, educational, or quality-improvement purposes (de-identified where applicable).

VII. UNFORESEEN CONDITIONS AND EXTENSION OF PROCEDURE

A. Extension Authorization. If, during Treatment, the clinician encounters an unforeseen condition that in the exercise of professional judgment requires additional or different procedures to protect Patient's life or health, Patient ☐ authorizes ☐ does not authorize such extension, subject to the limits stated below.

B. Limits / Exclusions. Patient excludes the following procedures from any such extension: [________________________________]

VIII. PRIVACY, RECORDS, AND COMMUNICATIONS

A. HIPAA / Confidentiality. Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands that PHI may be used and disclosed for treatment, payment, and health-care operations as permitted by 45 C.F.R. Part 164 and applicable North Dakota law.

B. Authorized Communications. Patient permits Provider to communicate Treatment-related information by:
☐ Voicemail to: [PHONE]
☐ Email to: [EMAIL]
☐ Patient portal / secure messaging
☐ Other: [____________________]

C. Designated Recipients. Provider may discuss Treatment with the following individuals: [NAMES / RELATIONSHIPS]

IX. FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS

A. Responsibility for Charges. Patient (or guarantor) is financially responsible for charges not paid by insurance, including deductibles, coinsurance, and non-covered services.

B. Assignment of Benefits. Patient assigns to Provider all insurance and government health-program benefits payable for Treatment, and authorizes direct payment to Provider.

C. Good-Faith Estimate. Where required under the federal No Surprises Act (Pub. L. 116-260), Patient has been offered a written good-faith estimate. ☐ Yes ☐ N/A

X. NO GUARANTEE OF OUTCOME

A. Acknowledgment. Patient acknowledges that the practice of medicine is not an exact science and that no representation, warranty, or guarantee has been made by Provider regarding the result, cure, or success of Treatment.

B. Voluntariness. Patient confirms that consent is given voluntarily, free from coercion, and after adequate opportunity to consider alternatives.

XI. GENERAL PROVISIONS

A. Governing Law. This Agreement is governed by the laws of the State of North Dakota, without regard to conflict-of-laws principles.

B. Severability. If any provision is held unenforceable, the remaining provisions shall continue in full force and effect.

C. Entire Agreement. This Agreement, together with any attachments and Provider's Notice of Privacy Practices, constitutes the entire agreement of the Parties concerning Patient's informed consent to Treatment.

D. Language and Interpreter. Consent was obtained in: ☐ English ☐ Other: [LANGUAGE]. Interpreter used: ☐ No ☐ Yes — [NAME, QUALIFICATIONS]

XII. EXECUTION

SOURCES AND REFERENCES

• Jaskoviak v. Gruver, 2002 ND 1, 638 N.W.2d 1 (reasonable-patient / materiality standard for informed consent).
• NDCC ch. 23-06.5 — Health Care Directives.
• NDCC § 14-10-01 — Age of majority (18).
• NDCC § 14-10-17; § 14-10-17.1 — Minor consent provisions (verify current subsection text with counsel).
• NDCC ch. 43-17 — North Dakota Medical Practice Act.
• 45 C.F.R. Part 164 — HIPAA Privacy Rule.
• North Dakota Board of Medicine guidance on informed consent.