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. Oklahoma and federal informed-consent requirements are complex and frequently updated; a qualified Oklahoma-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT AGREEMENT

(Oklahoma — Comprehensive Informed Consent Form)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions — Disclosure & Consent
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

A. Purpose. This Agreement records the informed consent of Patient (or Representative) for one or more medical treatments, procedures, or services (collectively, "Treatment") performed by Provider, in compliance with Oklahoma's reasonable / prudent patient standard for informed consent established by Scott v. Bradford, 1979 OK 165, 606 P.2d 554, and the written-consent provisions of 76 O.S. § 21.

B. Consideration. In consideration of Provider's agreement to furnish Treatment and related services, and other good and valuable consideration, the Parties agree as set forth herein.

C. Acknowledgment of Receipt. Patient acknowledges receipt of a copy of this Agreement and that its provisions have been explained in plain language Patient understands.

II. DEFINITIONS

"Adverse Event" — Any unanticipated injury or complication arising in connection with Treatment requiring further medical intervention.

"Advance Directive" — A living will, durable power of attorney for health care, or other directive executed under the Oklahoma Advance Directive Act, 63 O.S. § 3101.1 et seq.

"Capacity" — The ability to understand the nature, risks, benefits, and reasonable alternatives of Treatment and to make and communicate a decision, evaluated consistent with Oklahoma common law and 63 O.S. § 3101.4.

"Confidential Information" — Individually identifiable health information protected by HIPAA (45 C.F.R. parts 160 & 164) and Oklahoma law.

"Emergency Condition" — A condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function and informed consent cannot practicably be obtained.

"Informed Consent" — Voluntary authorization given by Patient or Representative after disclosure of (i) diagnosis, (ii) proposed Treatment and its nature, (iii) material risks and expected benefits, (iv) reasonable alternatives including the option of no treatment, and (v) answers to Patient's questions — sufficient to satisfy the reasonable / prudent patient standard of Scott v. Bradford, 1979 OK 165, 606 P.2d 554, and the written-consent provisions of 76 O.S. § 21.

"Material Risk" — A risk to which a reasonable person, in the Patient's position, would be likely to attach significance in deciding whether to undergo or forego the proposed Treatment (Scott v. Bradford).

"Parties" — Provider, Patient, and Representative (if any).

III. OPERATIVE PROVISIONS — DISCLOSURE & CONSENT

3.1 Description of Treatment

3.2 Disclosure Standard

Provider has disclosed, in language understandable to Patient, all information that a reasonable person in Patient's position would likely consider material under Scott v. Bradford. This consent is documented in writing as required by 76 O.S. § 21, which establishes a presumption of negligence where written informed consent is not properly obtained for specified procedures.

3.3 Voluntary Consent

Patient confirms consent is given voluntarily, without coercion or undue influence, and may be withdrawn in writing at any time prior to performance of Treatment, subject to Section VI.

3.4 Right to Ask Questions

Patient was encouraged to ask questions, and all questions were answered to Patient's satisfaction prior to signing.

3.5 Capacity Verification

Provider has verified that Patient possesses Capacity. If Patient lacks Capacity, consent has been obtained from a Representative authorized under:

• ☐ Healthcare Proxy / Durable Power of Attorney for Health Care (63 O.S. § 3101.4);
• ☐ Court-appointed Guardian of the Person (Title 30);
• ☐ Surrogate decision-maker as recognized under Oklahoma law;
• ☐ Patient's prior Advance Directive (63 O.S. § 3101.1 et seq.).

3.6 Hydration & Nutrition (Where Applicable)

If Treatment involves withholding or withdrawing artificially administered hydration or nutrition, the Parties shall comply with the Oklahoma Hydration and Nutrition for Incompetent Patients Act, 63 O.S. § 3081.1 et seq., including written directive requirements and physician documentation.

3.7 Minors

• ☐ Patient is age 18 or older (15 O.S. § 13).
• ☐ Patient is a minor; consent obtained from parent / legal guardian.
• ☐ Minor self-consent: STD diagnosis / treatment or family planning (63 O.S. § 2602).
• ☐ Minor self-consent: substance abuse treatment (63 O.S. § 2607).
• ☐ Emancipated minor (court order attached) or married minor.

3.8 Emergency Treatment Exception

In an Emergency Condition where informed consent cannot practicably be obtained, Provider may proceed with Treatment necessary to preserve life or limb consistent with Oklahoma common law and the implied-consent doctrine.

3.9 Confidentiality & Privacy

Provider will use Confidential Information solely for treatment, payment, and healthcare operations consistent with HIPAA. Patient acknowledges receipt of Provider's Notice of Privacy Practices.

3.10 Financial Responsibility

Patient agrees to be responsible for charges not covered by insurance, subject to applicable Oklahoma billing-disclosure rules. [INSERT BILLING POLICY OR ATTACH AS SCHEDULE 2.]

IV. REPRESENTATIONS & WARRANTIES

4.1 Patient / Representative Representations

(a) Authority & Identity. Representative warrants legal authority to act for Patient under an Advance Directive, guardianship order, or Oklahoma surrogate-decision-maker law.
(b) Accuracy of Information. All medical history, allergy, and medication information furnished to Provider is true, complete, and accurate.
(c) Understanding. Patient / Representative represents that the disclosures in Section III were understood.

4.2 Provider Representations

(a) Licensure. Provider and Treating Clinician are duly licensed in Oklahoma under 59 O.S. § 481 et seq.
(b) Standard of Care. Treatment will be rendered consistent with the prevailing professional standard of care in Oklahoma.
(c) Disclosure Compliance. Provider has made disclosures sufficient to satisfy Scott v. Bradford and 76 O.S. § 21.

4.3 Survival

Sections 4.1–4.2 survive completion or termination of Treatment to the extent necessary to enforce the Parties' rights.

V. COVENANTS & RESTRICTIONS

5.1 Patient Cooperation. Patient shall follow pre- and post-Treatment instructions and promptly notify Provider of any Adverse Event or material change in condition.

5.2 Provider Recordkeeping. Provider shall maintain medical records consistent with Oklahoma Administrative Code 435:10-7 and HIPAA retention requirements.

5.3 Insurance. Provider shall maintain professional liability insurance in amounts reasonable for the scope of practice.

VI. DEFAULT & REMEDIES

6.1 Events of Default.
(a) Non-payment by Patient.
(b) Material misrepresentation by any Party.
(c) Withdrawal of consent during a Procedure already in progress where withdrawal would create a greater risk of harm (subject to Patient's overriding right of refusal as recognized in Oklahoma).

6.2 Notice & Cure. The non-defaulting Party shall provide written notice specifying the default. The defaulting Party shall have ten (10) calendar days to cure a monetary default and a reasonable period (not to exceed fifteen (15) calendar days) to cure any non-monetary default.

6.3 Remedies.
(a) Suspension or termination of non-emergency Treatment;
(b) Recovery of reasonable collection costs and attorneys' fees for unpaid charges;
(c) Any other remedy available at law or equity, subject to Section VII.

VII. RISK ALLOCATION

7.1 Informed-Consent Protection. Patient agrees to indemnify and hold harmless Provider and its personnel from claims arising out of Patient's breach of this Agreement or failure to follow medical instructions, except to the extent caused by Provider's negligence or willful misconduct.

7.2 Limitation of Liability. Nothing in this Agreement limits Provider's liability for professional negligence beyond limits permitted under Oklahoma law.

7.3 Force Majeure. Provider shall not be liable for delay or failure to perform due to events beyond reasonable control (natural disaster, pandemic, governmental order), provided Provider exercises commercially reasonable efforts to mitigate.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. This Agreement is governed by the laws of the State of Oklahoma, without regard to conflict-of-laws principles.

8.2 Forum Selection. Exclusive venue shall lie in the District Court of the Oklahoma county in which Treatment is rendered, except as provided in Section 8.3.

8.3 Optional Arbitration.
☐ Patient elects binding arbitration under the Oklahoma Uniform Arbitration Act, 12 O.S. § 1851 et seq., administered by [AAA / JAMS / OTHER] under its healthcare rules.
☐ Patient declines arbitration; disputes resolved in District Court.

8.4 Jury Trial. If arbitration is not elected, the Parties acknowledge the constitutional right to a jury trial and do not waive that right herein.

8.5 Injunctive Relief. Either Party may seek limited injunctive relief only to protect PHI or enforce non-disclosure obligations.

IX. GENERAL PROVISIONS

9.1 Amendments & Waivers. Any amendment or waiver must be in a signed writing referencing this Agreement.

9.2 Assignment. Patient may not assign rights without Provider's prior written consent. Provider may assign to a successor entity.

9.3 Severability. If any provision is held invalid, the remaining provisions remain enforceable; the invalid provision shall be reformed to the minimum extent necessary.

9.4 Integration. This Agreement, together with all schedules and Provider's Notice of Privacy Practices, constitutes the entire agreement and supersedes all prior oral or written understandings.

9.5 Counterparts; Electronic Signatures. This Agreement may be executed in counterparts (including electronic signatures under Oklahoma's UETA, 12A O.S. § 15-101 et seq.), each of which is deemed an original.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

A. Patient / Representative

B. Provider / Treating Clinician

C. Witness (if required by facility policy)

SCHEDULE 1 — DISCLOSURE OF MATERIAL RISKS & ALTERNATIVES

[Use plain language understandable to Patient. Tailor disclosure to the specific procedure. Document all material risks under the Scott v. Bradford reasonable patient standard.]

SCHEDULE 2 — NOTICE OF PRIVACY PRACTICES

[Attach Provider's current HIPAA-compliant notice or incorporate by reference.]

SOURCES AND REFERENCES

• 76 O.S. § 21 — Presumption of negligence (informed consent)
• 63 O.S. § 3081.1 et seq. — Oklahoma Hydration and Nutrition for Incompetent Patients Act
• 63 O.S. § 3101.1 et seq. — Oklahoma Advance Directive Act
• 15 O.S. § 13 — Age of majority (18)
• 63 O.S. § 2602 — Minor consent (STD / family planning)
• 63 O.S. § 2607 — Minor consent (substance abuse)
• 59 O.S. § 481 et seq. — Oklahoma Medical Practice Act
• Scott v. Bradford, 1979 OK 165, 606 P.2d 554 — reasonable / prudent patient standard
• 45 C.F.R. parts 160 & 164 — HIPAA Privacy Rule