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. New Mexico and federal requirements governing informed consent and medical malpractice are complex; a qualified New Mexico-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT AGREEMENT

(New Mexico — Comprehensive Informed Consent Form)

I. LEGAL FRAMEWORK AND PURPOSE

This form documents the Patient's informed consent under New Mexico law, including:

• Gerety v. Demers, 92 N.M. 396 (1978) — New Mexico Supreme Court adopted the reasonable patient (materiality) standard: a physician must disclose all information a reasonable patient would consider material to the decision whether to undergo proposed treatment.
• NMSA § 24-7A-1 et seq. — Uniform Health-Care Decisions Act (capacity, surrogate decision-making, advance directives).
• NMSA § 24-7A-6.1 — Mental Health Care Treatment Decisions Act (separate consent rules for psychotropic medications and mental health interventions).
• NMSA § 24-1-9 — Minors of any age may consent to diagnosis and treatment of sexually transmitted disease and to family planning services without parental consent.
• NMSA § 32A-6A-15 — Minors aged 14 or older may consent to outpatient mental health and substance use treatment.

II. DEFINITIONS

III. DESCRIPTION OF PROPOSED TREATMENT

IV. DISCLOSURE OF MATERIAL RISKS, BENEFITS, AND ALTERNATIVES (Gerety v. Demers)

The clinician has disclosed, and the Patient acknowledges understanding of:

☐ The nature and purpose of the proposed Treatment.
☐ The material risks, including but not limited to: [LIST PROCEDURE-SPECIFIC RISKS — e.g., infection, bleeding, anesthesia complications, organ injury, death].
☐ The expected benefits and probability of success: [DESCRIBE].
☐ Reasonable alternatives, including no treatment, and their respective risks/benefits: [LIST].
☐ Probable consequences of refusing the Treatment.
☐ Any financial interest or referral relationship of the clinician that a reasonable patient would consider material.
☐ The identity of any non-physician practitioners who will participate.

V. CAPACITY DETERMINATION (NMSA § 24-7A-1, -11)

☐ Clinician has assessed Patient's capacity and finds the Patient possesses capacity to consent.
☐ Patient lacks capacity; consent is being obtained from a Surrogate under NMSA § 24-7A-5 in the following priority order: (1) spouse; (2) individual in long-term relationship of indefinite duration; (3) adult child; (4) parent; (5) adult sibling; (6) grandparent; (7) close friend.
☐ Patient has a validly executed Advance Health-Care Directive / Optional Advance Directive (NMSA § 24-7A-4) — attached.

VI. MINOR PATIENT PROVISIONS

Complete only if Patient is under 18.

Parent/Guardian Signature (if required): [_________________________] Date: [__/__/____]

VII. MENTAL HEALTH TREATMENT — SUPPLEMENTAL CONSENT (NMSA § 24-7A-6.1)

Complete only for psychotropic medication or mental health interventions.

☐ Patient has been informed of the specific medication(s), dosage range, expected therapeutic effect, and side effects.
☐ Patient has executed a Mental Health Treatment Power of Attorney or is acting through a designated surrogate.
☐ Court order / commitment authorization attached, if applicable.

VIII. SPECIFIC ACKNOWLEDGMENTS

☐ I have had an opportunity to ask questions, and my questions have been answered to my satisfaction.
☐ I understand no guarantee or warranty has been made about the results of the Treatment.
☐ I authorize the disposition of any tissue or specimens removed in accordance with provider policy and NM law.
☐ I authorize photography/recording for medical record purposes only [☐ Yes ☐ No].
☐ I consent to administration of blood/blood products if medically necessary [☐ Yes ☐ No].
☐ I have been advised of my right to refuse or withdraw consent at any time before the Treatment.
☐ I understand this consent will remain in effect for the duration of the described Treatment unless withdrawn in writing.

IX. INTERPRETER / LANGUAGE ACCESS

☐ Consent was provided in English.
☐ Interpreter provided. Language: [_______________]. Interpreter name & credential: [_______________].
☐ Patient confirms understanding of all material disclosures.

X. WITHDRAWAL OF CONSENT

Patient or Surrogate may withdraw consent at any time before the Treatment begins by oral or written notice to the treating clinician. Withdrawal will not affect treatment already rendered in good faith.

XI. SIGNATURES

XII. CLINICIAN ATTESTATION

I attest that I personally explained the nature, purpose, material risks, benefits, and reasonable alternatives of the proposed Treatment to the Patient or authorized Surrogate; that I answered all questions; that I believe the Patient/Surrogate understood the disclosures and voluntarily consented; and that this consent satisfies the reasonable-patient materiality standard of Gerety v. Demers, 92 N.M. 396 (1978), and NMSA § 24-7A-1 et seq.

Clinician Signature: [_____________________] NM License No.: [__________] Date: [__/__/____]

SOURCES AND REFERENCES

• Gerety v. Demers, 92 N.M. 396, 589 P.2d 180 (1978).
• NMSA 1978, Chapter 24, Article 7A — Uniform Health-Care Decisions Act.
• NMSA 1978, § 24-7A-6.1 — Mental Health Care Treatment Decisions Act.
• NMSA 1978, § 24-1-9 — Minor consent for STD/family planning services.
• NMSA 1978, § 32A-6A-15 — Mental health minor consent (age 14+).
• New Mexico Medical Board, NMAC Title 16, Chapter 10 (Medicine and Surgery Practitioners).