South Dakota Patient Informed Consent Form for Medical Treatment

PATIENT INFORMED CONSENT FOR MEDICAL TREATMENT

State of South Dakota

1. Patient and Provider Information

2. Proposed Treatment or Procedure

The patient has been advised that the following treatment, procedure, or course of care is recommended:

Description of Treatment/Procedure:
[____________________________________________________________]

Diagnosis or Clinical Indication:
[____________________________________________________________]

Anticipated Date(s) of Treatment: [__/__/____] through [__/__/____]

3. Disclosure Required by South Dakota Law

Under SDCL § 20-9-1.1 and Wheeldon v. Madison, 374 N.W.2d 367 (S.D. 1985), the treating provider must disclose all information that a reasonable person in the patient's position would consider material to the decision to accept or reject the proposed treatment. The patient acknowledges that the provider has disclosed and discussed each of the following:

☐ The nature and purpose of the proposed treatment or procedure
☐ The material risks, complications, and known adverse outcomes reasonably foreseeable
☐ The probable benefits and expected results
☐ Reasonable alternative treatments or procedures (including no treatment) and their risks/benefits
☐ The anticipated recovery, follow-up care, and limitations after treatment
☐ The identity and role of all providers expected to participate in the treatment
☐ Any material financial interest of the provider in the recommended treatment

Specific Material Risks Disclosed (procedure-specific):
[____________________________________________________________]
[____________________________________________________________]

Reasonable Alternatives Discussed:
[____________________________________________________________]

4. Anesthesia, Sedation, and Ancillary Procedures

☐ No anesthesia or sedation is anticipated.
☐ The patient consents to the following anesthesia/sedation: [____________________]
☐ The patient consents to the administration of blood or blood products if medically indicated.
☐ The patient consents to disposal or laboratory analysis of tissue/specimens removed.
☐ The patient consents to photography/video for documentation of the procedure (medical record only).

5. Patient Capacity and Authority to Consent

Select the applicable basis for consent:

☐ Adult patient (18 or older) with decisional capacity — signing on own behalf.
☐ Emancipated or married minor — signing on own behalf under South Dakota law.
☐ Minor self-consent for limited categories permitted by South Dakota law:
☐ Voluntary substance abuse treatment (SDCL § 34-20A-50)
☐ Emergency treatment where delay would threaten life or health (SDCL § 20-9-4.2)
☐ Other statutory category: [____________________]
☐ Parent / legal guardian consent on behalf of minor patient.
☐ Healthcare agent under durable power of attorney for healthcare (SDCL ch. 59-7).
☐ Living will / advance directive controls (SDCL ch. 34-12D).
☐ Court-appointed guardian / conservator — Order dated [__/__/____].

Name of Person Consenting (if not patient): [________________________________]
Relationship / Legal Authority: [________________________________]

6. Acknowledgment of Understanding

The patient (or authorized representative) acknowledges:

☐ I have read this form and had it explained to me in language I understand.
☐ I have had the opportunity to ask questions, and my questions have been answered.
☐ I understand that the practice of medicine is not an exact science and no guarantee of results has been made.
☐ I understand I may withdraw this consent at any time before the treatment is performed.
☐ I have been provided a copy of the facility's Notice of Privacy Practices (HIPAA, 45 C.F.R. § 164.520).
☐ I consent to the proposed treatment described above.

7. Refusal of Recommended Treatment (if applicable)

☐ The patient has been informed of the recommended treatment and refuses all or part of it.

Treatment Refused: [____________________________________________________________]

Material Risks of Refusal Disclosed: [____________________________________________________________]

The patient acknowledges that refusal may result in serious harm, including worsening of the condition, permanent injury, or death, and accepts responsibility for that decision.

8. Signatures

Language of Discussion / Interpreter Service: [____________________]

9. Provider Attestation

I certify that I have personally discussed the proposed treatment, material risks, reasonable alternatives, and probable benefits with the patient (or authorized representative); that I provided the disclosures required by SDCL § 20-9-1.1 and applicable South Dakota case law; and that, to the best of my judgment, the patient (or representative) has the capacity to consent and has done so voluntarily.

Provider Signature: [____________________] Date: [__/__/____]

Sources and References

• SDCL Title 20, Chapter 9 — Liability for Torts (informed consent): https://sdlegislature.gov/Statutes/20-9
• Wheeldon v. Madison, 374 N.W.2d 367 (S.D. 1985): https://law.justia.com/cases/south-dakota/supreme-court/1985/14387-1.html
• SDCL Title 26 — Minors: https://sdlegislature.gov/Statutes/26
• SDCL Chapter 34-20A — Treatment and Prevention of Alcohol and Drug Abuse: https://sdlegislature.gov/Statutes/34-20A
• SDCL Chapter 34-12D — Living Wills: https://sdlegislature.gov/Statutes/34-12D
• SDCL Chapter 59-7 — Power of Attorney: https://sdlegislature.gov/Statutes/59-7
• SDCL § 36-4-30 — Unprofessional conduct: https://sdlegislature.gov/Statutes/36-4-30
• HHS HIPAA Privacy Rule: https://www.hhs.gov/hipaa/for-professionals/privacy/