PATIENT CONSENT FORM – TREATMENT

(South Carolina – Comprehensive Informed Consent)

[// GUIDANCE: This template is intentionally comprehensive to satisfy South Carolina’s stringent informed-consent rules and to give counsel maximum flexibility. Delete any provisions that are unnecessary for the contemplated course of treatment.]

I. DOCUMENT HEADER

1. Parties
   1.1 Provider: [LEGAL NAME OF HEALTHCARE ENTITY], a [South Carolina-organized professional corporation/LLC] with its principal place of business at [ADDRESS] (“Provider”).
   1.2 Patient: [FULL LEGAL NAME], date of birth [MM/DD/YYYY], residing at [ADDRESS] (“Patient”). If the Patient lacks Capacity (as defined below), all references to “Patient” include the duly Authorized Representative executing this Form on the Patient’s behalf.

2. Recitals
   A. Provider will furnish certain medical, surgical, diagnostic, therapeutic, or other health-care services as described herein (collectively, the “Treatment”).
   B. South Carolina law requires that Provider obtain the Patient’s voluntary, informed consent prior to administering Treatment.
   C. The parties wish to set forth their respective rights, duties, and obligations to ensure compliance with the South Carolina Adult Health Care Consent Act and other applicable law.

3. Effective Date: [DATE] (“Effective Date”).

4. Governing Law: This Form shall be governed by the laws of the State of South Carolina, without regard to conflict-of-law principles.

TABLE OF CONTENTS

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

II. DEFINITIONS

For ease of reference, the following terms shall have the meanings set forth below (terms defined in the singular include the plural and vice versa):

“Acknowledgment” – written confirmation by Patient that required disclosures were provided and understood.
“Authorized Representative” – an individual authorized under applicable law to consent on behalf of a Patient who lacks Capacity.
“Capacity” – the ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health-care decision.
“Covered Claim” – any claim alleging insufficient informed consent, breach of this Form, or violation of privacy arising out of the Treatment.
“Informed Consent Standards” – the disclosure and consent requirements mandated by South Carolina law and prevailing medical practice.
“PHI” – Protected Health Information, as defined by the Health Insurance Portability and Accountability Act (“HIPAA”).
“State Court” – a court of competent jurisdiction located within the State of South Carolina.
“Treatment” – the medical assessment, intervention, procedure, or course of therapy identified in Section III.1, together with ancillary services reasonably related thereto.

III. OPERATIVE PROVISIONS

1. Description of Treatment
   Provider will perform the following Treatment: [DETAILED DESCRIPTION OF PROCEDURE(S) OR COURSE OF CARE], including any anesthesia, medications, labs, imaging, or devices customarily associated therewith.

2. Disclosure of Material Information
   Provider has disclosed and Patient acknowledges receipt and understanding of:
   a. The nature and purpose of the Treatment;
   b. The material risks and expected benefits;
   c. Reasonable alternatives and their risks/benefits;
   d. The likely results of declining Treatment;
   e. The name, credentials, and role of all primary practitioners;
   f. Financial responsibility, including estimated charges and insurance billing practices; and
   g. Provider’s ownership or economic interest in any facility, pharmacy, or ancillary service utilized.

3. Right to Ask Questions
   Patient may ask questions at any time and is encouraged to do so until fully satisfied.

4. Voluntariness & Withdrawal
   Patient’s consent is voluntary and may be revoked orally or in writing at any time before or during Treatment, subject to Section VI.2 (Consequences of Revocation).

5. Capacity Verification
   Provider has assessed that Patient possesses Capacity, or, if not, that an Authorized Representative is executing this Form in compliance with the South Carolina Adult Health Care Consent Act.

IV. REPRESENTATIONS & WARRANTIES

1. Provider’s Representations
   a. Provider is duly licensed and in good standing under South Carolina law.
   b. Provider will render Treatment in accordance with applicable professional standards, including the Informed Consent Standards.
   c. Provider carries professional liability insurance meeting or exceeding statutory minimums.

2. Patient’s Representations
   a. Patient has accurately disclosed medical history, current medications, allergies, and other material information.
   b. Patient has had adequate opportunity to review disclosures and ask questions.
   c. Patient is not acting under duress or undue influence.

3. Survival
   The representations and warranties in this Section survive completion of Treatment.

V. COVENANTS & RESTRICTIONS

1. Patient Covenants
   a. Follow pre- and post-Treatment instructions.
   b. Promptly report unexpected side effects or complications.
   c. Fulfill financial obligations in accordance with Provider’s payment policies.

2. Provider Covenants
   a. Maintain confidentiality of PHI in compliance with HIPAA.
   b. Provide timely access to medical records as required by law.
   c. Notify Patient of any material changes to Treatment plan.

VI. DEFAULT & REMEDIES

1. Events of Default
   a. Patient’s failure to honor financial commitments.
   b. Provider’s material breach of professional or statutory duties.
   c. Revocation of consent without reasonable notice where such revocation jeopardizes Patient’s health or safety.

2. Consequences of Revocation
   Upon revocation, Provider may (i) suspend or terminate Treatment, (ii) transfer Patient’s care, and (iii) bill for services rendered to date.

3. Cure Periods
   Where practicable, the non-defaulting party shall give written notice and a reasonable opportunity to cure before pursuing remedies.

4. Attorney’s Fees
   The prevailing party in any action to enforce this Form is entitled to reasonable attorney’s fees and costs.

VII. RISK ALLOCATION

1. Indemnification (Informed-Consent Protection)
   To the fullest extent permitted by law, Patient shall defend, indemnify, and hold harmless Provider and its personnel from Covered Claims arising solely from an allegation of lack of informed consent, provided that Provider has complied with the Informed Consent Standards set forth herein.
   [// GUIDANCE: South Carolina public policy prohibits indemnification for a provider’s own negligence. The above carve-out is narrowly drafted to cover only consent-related claims.]

2. Limitation of Liability
   Except for (i) gross negligence, (ii) willful misconduct, or (iii) damages that may not lawfully be limited, Provider’s liability for non-economic damages related to the Treatment shall not exceed the statutory cap on medical-malpractice damages in effect at the time the cause of action accrues.

3. Insurance
   Provider shall maintain professional liability insurance with limits of not less than [AMOUNT] per incident and [AMOUNT] in the aggregate.

4. Force Majeure
   Neither party is liable for delay or failure in performance due to events beyond reasonable control, including pandemics, natural disasters, or governmental mandates.

VIII. DISPUTE RESOLUTION

1. Informal Conference
   The parties shall first attempt to resolve any dispute through good-faith discussion within 30 days of written notice.

2. Optional Arbitration
   a. Election. By initialing below, both parties may elect binding arbitration under the South Carolina Uniform Arbitration Act:
   Provider Initials: _ Patient/Rep Initials: _
   b. Rules. Arbitration shall be administered by [NAMED ADR ORGANIZATION] under its Healthcare Arbitration Rules.
   c. Waiver of Jury. By electing arbitration, the parties knowingly waive the constitutional right to a jury trial.

3. Forum Selection
   Absent an arbitration election, any action arising out of or relating to this Form shall be brought exclusively in State Court.

4. Injunctive Relief
   A party may seek temporary or preliminary injunctive relief only to preserve the status quo pending resolution of a dispute and only to the extent necessary to prevent irreparable harm.

IX. GENERAL PROVISIONS

1. Amendments & Waivers
   No amendment or waiver is effective unless in writing and signed by the party against whom enforcement is sought.

2. Assignment
   Patient may not assign rights or delegate duties without Provider’s prior written consent.

3. Successors & Assigns
   This Form binds and benefits the parties and their respective successors and permitted assigns.

4. Severability
   If any provision is held unenforceable, the remaining provisions shall be enforced to the maximum extent permitted, and the invalid provision reformed to reflect the parties’ intent.

5. Integration
   This Form constitutes the entire agreement regarding informed consent for the Treatment and supersedes all prior or contemporaneous understandings.

6. Counterparts; Electronic Signatures
   This Form may be executed in counterparts, each of which is deemed an original. Electronic signatures are as enforceable as originals.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the parties have executed this Patient Consent Form – Treatment as of the Effective Date.

PROVIDER
By: ____
Name: ____
Title: _____
Date: _________

PATIENT (or Authorized Representative)
Signature: ____
Name: ____
Capacity/Relationship (if not Patient): __
Date: ________

WITNESS (recommended)
Signature: ____
Name: ____
Date: _________

NOTARY ACKNOWLEDGMENT (if required)
State of South Carolina, County of __
Subscribed and sworn before me on _, 20 by ____, personally known to me or proven on the basis of satisfactory evidence to be the signer of the foregoing instrument.
Notary Public Signature: __
My Commission Expires: _____

[// GUIDANCE:
1. Review South Carolina Code §§ 15-32-200 et seq. and the Adult Health Care Consent Act to confirm any updates before finalizing.
2. Confirm your malpractice carrier’s requirements regarding arbitration language and liability caps.
3. Delete the notary block if executing in a healthcare facility that does not require notarization.]