Patient Consent Form - Treatment

PATIENT CONSENT TO MEDICAL TREATMENT

(Comprehensive Informed Consent & Treatment Agreement — Oregon)

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 Title; Parties

This Patient Consent to Medical Treatment Agreement (the “Agreement”) is entered into by and between [FULL LEGAL NAME OF HEALTH-CARE PROVIDER], an Oregon licensed [physician/physician group/hospital/clinic] (“Provider”), and [FULL LEGAL NAME OF PATIENT] (“Patient”).

1.2 Effective Date

Effective as of [DATE] (the “Effective Date”).

1.3 Recitals

A. Provider will furnish the medical treatment(s) and/or diagnostic procedure(s) described herein (collectively, the “Treatment”).
B. Patient desires to receive the Treatment and, in accordance with applicable Oregon informed-consent law, wishes to evidence Patient’s informed, voluntary, and competent consent.
C. In consideration of the mutual promises contained herein, the parties agree as follows.

2. DEFINITIONS

For purposes of this Agreement, the following terms have the meanings set forth below. Undefined capitalized terms have the meanings ascribed elsewhere herein.

2.1 “Capacity” means the legal and mental ability under Oregon law to understand Treatment information and to make and communicate health-care decisions.

2.2 “Complication” means any adverse, unintended, or unexpected outcome associated with the Treatment.

2.3 “Dispute” has the meaning set forth in Section 8.1.

2.4 “Emergency” means a circumstance in which delaying Treatment to obtain formal consent would seriously jeopardize the Patient’s life or health.

2.5 “Protected Health Information” or “PHI” has the meaning assigned under 45 C.F.R. § 160.103.

2.6 “Treatment Plan” means the proposed course of Treatment described in Section 3.2.

3. OPERATIVE PROVISIONS

3.1 Confirmation of Capacity

Patient represents that Patient (i) is [≥ 18 years old / ≥ 15 years old per OR minor-consent statute / emancipated / otherwise authorized] or that Patient’s [parent/legal guardian] executes this Agreement on Patient’s behalf; and (ii) possesses Capacity, absent which Provider shall seek appropriate surrogate consent.

3.2 Description of Proposed Treatment

Provider has explained, and Patient acknowledges understanding of, each of the following:

a. Nature and purpose of the Treatment: [DETAILED DESCRIPTION]
b. Anticipated benefits: [BENEFITS]
c. Material risks and foreseeable Complications, including but not limited to [RISKS].
d. Reasonable alternatives (including the option of no Treatment) and their respective risks and benefits.
e. Estimated recovery time and post-Treatment limitations.
f. Provider’s credentials and involvement of residents/advanced practice providers, if any.

3.3 Patient Questions & Voluntary Consent

Patient acknowledges the opportunity to ask questions and that all questions were answered to Patient’s satisfaction. Patient voluntarily consents to the Treatment Plan.

3.4 Continuing Right to Withdraw

Patient may revoke consent at any time before or during the Treatment, except where immediate continuation is medically necessary to prevent serious harm (Emergency).

3.5 Ancillary Services & Additional Procedures

Patient authorizes Provider to perform such additional or different procedures as Provider deems medically necessary during the course of the Treatment, provided that such procedures are within the scope of informed consent standards or necessitated by unforeseen conditions.

3.6 Financial Responsibility

Patient (or guarantor) accepts responsibility for payment of charges, copayments, deductibles, and non-covered services in accordance with Provider’s Financial Policy attached hereto as Exhibit A.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient’s Representations
a. Patient has accurately disclosed all material medical history, medications, allergies, and relevant lifestyle factors.
b. Patient is not relying on any statement or guarantee regarding outcomes except as expressly set forth herein.

4.2 Provider’s Representations
a. Provider and all persons performing the Treatment hold valid and unencumbered Oregon licenses and privileges.
b. Provider will perform the Treatment in accordance with the standard of care prevailing in the Oregon medical community for similar professionals and procedures.

4.3 Survival
The representations and warranties in this Section 4 survive completion of the Treatment and any termination of this Agreement to the extent permitted by Oregon law.

5. COVENANTS & RESTRICTIONS

5.1 Patient Covenants
a. Compliance with pre- and post-Treatment instructions and follow-up appointments.
b. Notification of Provider regarding any adverse change in condition.
c. Payment in accordance with Section 3.6.

5.2 Provider Covenants
a. Maintenance of Patient’s confidentiality in compliance with HIPAA and Oregon privacy statutes.
b. Provision of emergency contact information and reasonable post-Treatment availability.

5.3 Prohibited Actions
Neither party shall record audio or video of the Treatment without the other party’s prior written consent, except as required by law.

6. DEFAULT & REMEDIES

6.1 Events of Default
a. Patient’s failure to pay undisputed amounts when due.
b. Willful failure to adhere to critical medical instructions that materially increases risk.
c. Provider’s breach of the standard of care or confidentiality obligations.

6.2 Notice & Cure
The non-defaulting party shall provide written notice specifying the default. The defaulting party has [15] calendar days (or a shorter reasonable period in medical emergencies) to cure.

6.3 Remedies
a. Suspension or termination of Treatment (Provider).
b. Referral to collections for unpaid balances (Provider).
c. Administrative or licensing board complaint (Patient).
d. Any other remedy available at law or in equity, subject to the limitations in Section 7.

7. RISK ALLOCATION

7.1 Indemnification — Informed Consent Protection

Patient shall indemnify, defend, and hold harmless Provider from losses, claims, or liabilities arising out of Patient’s misrepresentation or concealment of material medical information, except to the extent caused by Provider’s negligence or willful misconduct.

7.2 Limitation of Liability

Except for (i) damages that cannot be limited under Oregon law, and (ii) Provider’s gross negligence or willful misconduct, Provider’s aggregate liability to Patient shall not exceed the applicable statutory malpractice cap in effect at the time of the alleged injury (the “Cap”). The Cap shall be automatically adjusted to reflect any future amendments to Oregon malpractice-limit statutes.

7.3 Insurance

Provider represents the maintenance of professional liability insurance meeting or exceeding Oregon’s minimum coverage requirements.

7.4 Force Majeure

Neither party is liable for delay or failure to perform any non-medical obligation under this Agreement due to events beyond its reasonable control, including act of God, pandemic, or governmental action.

8. DISPUTE RESOLUTION

8.1 Definition of Dispute

“Dispute” means any disagreement arising out of or relating to this Agreement, the Treatment, or any alleged breach, except claims within the exclusive jurisdiction of Oregon’s medical board.

8.2 Internal Resolution; Mediation

The parties shall first attempt good-faith negotiation followed, if unresolved within [30] days, by non-binding mediation in [COUNTY], Oregon.

8.3 Arbitration (Optional Election)

Check one:
☐ Binding Arbitration: Disputes shall be resolved by confidential, final, and binding arbitration administered by [ADR ORGANIZATION] under its health-care rules.
☐ No Arbitration: Parties reserve the right to litigate in state court.

8.4 Governing Law & Forum Selection

This Agreement is governed by the laws of the State of Oregon, without regard to conflict-of-law principles. Unless arbitration is elected, the parties consent to exclusive jurisdiction and venue in the state courts of [COUNTY], Oregon.

8.5 Jury-Trial Waiver

To the fullest extent permitted by the Oregon Constitution, each party knowingly and voluntarily waives its right to a trial by jury for any Dispute, provided that such waiver will not apply if (i) prohibited by Oregon law or (ii) Patient opts out within [30] days of signing by delivering written notice to Provider.

8.6 Injunctive Relief

Nothing herein authorizes injunctive relief beyond that necessary to preserve the status quo of PHI confidentiality or to enforce Section 5.3’s recording prohibition.

9. GENERAL PROVISIONS

9.1 Amendments & Waivers
No amendment or waiver is effective unless in writing and signed by both parties.

9.2 Assignment
Neither party may assign this Agreement without the other’s prior written consent, except Provider may assign to an entity under common control.

9.3 Severability
If any provision is held invalid under applicable law, it shall be reformed to the minimum extent necessary, and the remainder of this Agreement shall remain in force.

9.4 Integration
This Agreement, together with all attached exhibits, constitutes the entire understanding between the parties and supersedes all prior oral or written agreements relating to its subject matter.

9.5 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, including PDF or electronic signatures, each of which constitutes an original and all of which together constitute one instrument.

10. EXECUTION BLOCK

If Patient is a minor or lacks Capacity:

Authorized Representative (Parent/Guardian/Agent):
Name: ___________________________
Relationship: ____________________
Signature: _______________________ Date: _____________

ACKNOWLEDGMENT OF RECEIPT & UNDERSTANDING

Patient (or Authorized Representative) acknowledges having received, read, and understood this Agreement and the attached Exhibit A (Financial Policy) and Exhibit B (Notice of Privacy Practices), and affirms that all questions have been answered.

Initials: _________