INFORMED CONSENT TO MEDICAL TREATMENT

(Nevada – Comprehensive Form)

[// GUIDANCE: This template is intentionally robust to satisfy Nevada’s statutory informed-consent framework (see, e.g., Nev. Rev. Stat. § 41A.110) and to withstand scrutiny in malpractice litigation. Delete bracketed guidance before finalizing.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Parties.
 (a) Provider: [LEGAL NAME OF HEALTHCARE ENTITY], a [STATE] [corporation / LLC / partnership] doing business as “[DBA],” together with its employed and contracted physicians, physician assistants, nurse practitioners, nurses, technicians, and other agents (collectively, “Provider”).
 (b) Patient: [PATIENT LEGAL NAME], date of birth: [MM/DD/YYYY] (“Patient”).
 (c) Patient Representative (if applicable under Section 2.1(g)): [NAME], relationship: [RELATIONSHIP].

1.2 Recitals.
 (A) Provider has recommended that Patient undergo the medical treatment, procedure, therapy, or series of interventions identified herein (the “Procedure”).
 (B) Nevada law requires that Patient receive and understand certain information concerning the Procedure before providing voluntary consent.
 (C) Patient desires to authorize Provider to perform the Procedure in accordance with applicable law and the terms of this Consent.

1.3 Effective Date. This Consent is effective upon the last signature in Section 10.

1.4 Governing Jurisdiction. This Consent is governed by the medical-practice laws of the State of Nevada.

2. DEFINITIONS

For ease of reference, capitalized terms have the meanings assigned below.

“Capacity Requirements” means the mental competence standards under Nevada law for making healthcare decisions, including those addressed in Nev. Rev. Stat. ch. 162A and ch. 449A.

“Complication” means any unintended or adverse outcome, side effect, or injury related to the Procedure or after-care, whether or not foreseeable.

“Healthcare Decision-Maker” means the Patient, or if the Patient lacks decision-making capacity, the individual authorized under an advance directive or Nevada law to make healthcare decisions on the Patient’s behalf.

“Informed Consent” has the meaning set out in Nev. Rev. Stat. § 41A.110 and, for purposes of this document, includes the disclosures and acknowledgments required under Section 3.

“Material Risks” means those risks that a reasonably prudent patient in the Patient’s position would consider significant when deciding whether to undergo the Procedure.

“Procedure Date” means the date on which the first component of the Procedure is initiated.

“Statutory Disclosure” means the information that Nevada law requires a physician to disclose to obtain valid Informed Consent, including: (i) a general explanation of the Procedure; (ii) alternatives; (iii) reasonably foreseeable Material Risks; and (iv) the name of the person responsible for the Procedure.

3. OPERATIVE PROVISIONS

3.1 Description of Procedure.
 Provider will perform: [DETAILED DESCRIPTION OF TREATMENT/PROCEDURE], to be conducted at [FACILITY NAME & ADDRESS] on or about [PROCEDURE DATE].

3.2 Disclosure & Acknowledgment.
 (a) Provider has supplied and explained to Patient each Statutory Disclosure element, including:
  (i) Nature and purpose of the Procedure;
  (ii) Viable alternative treatments (and choice of no treatment);
  (iii) Material Risks and Complications, including but not limited to: [ENUMERATE];
  (iv) Expected benefits and likelihood of success; and
  (v) Name(s) of treating practitioner(s).
 (b) Patient affirms that all questions have been answered to Patient’s satisfaction.

3.3 Right to Withdraw. Patient may revoke this Consent at any time before the Procedure begins, without penalty, by delivering written or oral notice to Provider.

3.4 Medication, Anesthesia & Blood Products.
 (a) Patient consents to administration of necessary pharmaceuticals, sedatives, anesthesia (local, regional, or general), and blood products deemed clinically appropriate.
 (b) Patient acknowledges associated Material Risks have been explained.

3.5 Post-Procedure Obligations. Patient agrees to comply with all post-operative instructions and follow-up appointments.

3.6 Capacity & Voluntariness.
 Patient (or Healthcare Decision-Maker) represents having full Capacity Requirements and that consent is voluntary and not induced by coercion, fraud, or undue influence.

4. REPRESENTATIONS & WARRANTIES

4.1 By Patient / Healthcare Decision-Maker:
 (a) Information supplied in medical history is complete and accurate.
 (b) Patient has had adequate time to review printed materials and ask questions.
 (c) No guarantee or warranty has been made concerning outcome or cure.

4.2 By Provider:
 (a) Provider and each practitioner are duly licensed and in good standing in Nevada.
 (b) Provider will exercise the degree of care, skill, and learning ordinarily possessed and exercised by members of the medical profession in similar circumstances.
 (c) Provider maintains professional liability insurance as required by Nevada law.

4.3 Survival. The representations and warranties in this Section survive completion of the Procedure.

5. COVENANTS & RESTRICTIONS

5.1 Patient Covenants.
 (a) Provide updated health information promptly.
 (b) Adhere to pre-procedure preparation instructions (e.g., fasting, medication adjustments).
 (c) Arrange for post-procedure transportation if sedation is administered.

5.2 Provider Covenant. Provider will maintain records and confidentiality in accordance with HIPAA and applicable Nevada privacy statutes.

5.3 Non-Transferability. Patient may not assign rights or obligations under this Consent.

6. DEFAULT & REMEDIES

6.1 Events of Default.
 (a) Patient’s material misrepresentation or omission of health information.
 (b) Patient’s failure to follow critical post-procedure instructions that materially increases Complication risk.

6.2 Provider Remedies.
 Upon default, Provider may:
  (i) Terminate the provider-patient relationship after giving reasonable notice;
  (ii) Bill Patient for additional medically-necessary services arising from default; and
  (iii) Seek indemnification per Section 7.1.

6.3 Notice & Cure. Provider will give written notice of default; Patient shall have ten (10) calendar days to cure where medically feasible.

7. RISK ALLOCATION

7.1 Indemnification—Informed-Consent Protection.
 Patient shall indemnify, defend, and hold harmless Provider from and against any Losses (excluding those arising from Provider’s professional negligence) attributable to:
 (a) Patient’s breach of Section 4.1 or 5.1; or
 (b) Claims by third parties resulting from Patient’s unauthorized disclosure of confidential information.

7.2 Limitation of Liability.
 Nothing in this Consent waives or enlarges the statutory cap on noneconomic damages in professional-negligence actions, currently set at $350,000. See Nev. Rev. Stat. § 41A.31.

7.3 No Guarantee of Outcome. Patient acknowledges medical results vary and that Provider has made no guarantee of cure.

7.4 Force Majeure. Provider shall not be liable for delay or inability to perform due to causes beyond reasonable control, including natural disasters and government orders.

8. DISPUTE RESOLUTION

8.1 Governing Law. This Consent shall be construed in accordance with the laws of the State of Nevada (“state_medical_law”).

8.2 Forum Selection. Exclusive venue lies in the state courts of [COUNTY], Nevada (“state_court”).

8.3 Optional Arbitration.
 (a) Patient may elect binding arbitration under the rules of the American Arbitration Association (“AAA”) by initialing here: ______.
 (b) If elected, arbitration will occur in [CITY], Nevada, before a single arbitrator who is a licensed Nevada attorney with at least ten (10) years’ healthcare experience.
 (c) Provider shall pay the initial filing fee; remaining costs shared equally unless otherwise awarded.

8.4 Jury Trial Preservation. If arbitration is not elected, each party retains its constitutional right to a trial by jury.

8.5 Limited Injunctive Relief. Either party may seek temporary or preliminary injunctive relief solely to protect medical confidentiality or preserve evidence; such actions shall not constitute a waiver of Section 8.3.

9. GENERAL PROVISIONS

9.1 Amendments & Waivers. Must be in writing and signed by both parties. No oral modifications shall be effective.

9.2 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force, and the parties agree to substitute a valid provision that most closely reflects the original intent.

9.3 Integration. This Consent constitutes the entire agreement concerning the subject matter and supersedes all prior oral or written communications.

9.4 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each deemed an original. Signatures delivered electronically or by facsimile are binding.

9.5 HIPAA Acknowledgment. Patient acknowledges receipt of Provider’s Notice of Privacy Practices.

9.6 Successors & Assigns. This Consent binds and benefits the parties and their respective legal representatives, heirs, and permitted assigns.

10. EXECUTION BLOCK

[// GUIDANCE: Notarization is generally not required for medical consents in Nevada, but a facility may add a jurat if desired.]

NOTICE TO PATIENT
1. You have the right to the information necessary to give Informed Consent.
2. You may refuse the proposed Procedure and be informed of alternatives.
3. Signing this form is voluntary and indicates understanding, not waiver of rights.

END OF DOCUMENT