PATIENT CONSENT FORM – TREATMENT
State of Tennessee
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Consent to Treatment
3.2 Scope of Authorized Treatment
3.3 Disclosure of Risks, Benefits, and Alternatives
3.4 Anesthesia and Sedation
3.5 Capacity and Voluntariness
3.6 Right to Withdraw Consent
3.7 Financial Responsibility - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
THIS PATIENT CONSENT FORM – TREATMENT (the “Consent”) is entered into and is effective as of [EFFECTIVE DATE] (the “Effective Date”) by and between:
• [PATIENT NAME], residing at [PATIENT ADDRESS] (the “Patient”); and
• [PROVIDER NAME], a [LEGAL ENTITY TYPE] duly organized under the laws of the State of Tennessee, with its principal place of business at [PROVIDER ADDRESS] (the “Provider”).
RECITALS
A. The Patient seeks to undergo the medical treatment, procedure, or course of care described herein (the “Procedure”).
B. The Provider is willing to render the Procedure subject to the Patient’s informed and voluntary consent in accordance with applicable Tennessee informed-consent standards and professional regulations.
In consideration of the mutual promises set forth herein and other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:
2. DEFINITIONS
The following terms, when used with initial capital letters, shall have the meanings set forth below. Undefined capitalized terms carry their ordinary clinical or legal meaning.
“Applicable Law” means all federal, state, and local statutes, regulations, and professional licensing rules governing the Provider’s practice, including without limitation Tennessee informed-consent requirements and malpractice liability statutes.
“Authorized Representative” means a person legally empowered to act on the Patient’s behalf, including but not limited to a parent, legal guardian, or holder of a valid healthcare power of attorney.
“Facility” means the hospital, clinic, or office where the Procedure is to be performed, identified as [FACILITY NAME/ADDRESS].
“Procedure” means the specific medical treatment, operation, therapy, diagnostic test, or series of related interventions described in Section 3.2.
“Protected Information” means individually identifiable health information subject to protection under HIPAA and similar state privacy laws.
“Provider Personnel” means physicians, nurses, technicians, contractors, and other individuals under the Provider’s supervision participating in the Procedure.
3. OPERATIVE PROVISIONS
3.1 Consent to Treatment
The Patient hereby voluntarily and knowingly authorizes the Provider and Provider Personnel to perform the Procedure, to administer any related medications, blood products, anesthesia, laboratory tests, radiological studies, or other supportive measures deemed medically necessary, and to employ such assistance as reasonably required.
3.2 Scope of Authorized Treatment
[// GUIDANCE: Insert a narrative description precise enough to satisfy Tennessee’s “reasonable patient” disclosure standard.]
The Procedure shall consist of:
• Nature of treatment: [DESCRIPTION OF PROCEDURE];
• Expected duration: [ESTIMATED TIMEFRAME]; and
• Post-operative or follow-up care: [POST-CARE PLAN].
Any material deviation from the above must be separately consented to unless emergent circumstances create a threat to life or serious bodily function.
3.3 Disclosure of Risks, Benefits, and Alternatives
The Provider has explained, and the Patient acknowledges understanding of:
a. Material risks and potential complications, including but not limited to: [LIST OF RISKS].
b. Expected benefits and likelihood of success: [OVERVIEW OF BENEFITS].
c. Reasonable alternative treatments, including the option of no treatment, and their attendant risks and benefits.
d. Name(s) of individual(s) primarily responsible for the Patient’s care and their professional credentials.
[// GUIDANCE: Ensure risk disclosure aligns with T.C.A. § 63-6-218 and Tennessee common-law “prudent patient” test.]
3.4 Anesthesia and Sedation
If anesthesia or sedation is required, the type (local, regional, general) and attendant risks (including respiratory or cardiovascular complications, allergic reaction, awareness under anesthesia) have been disclosed. The Patient consents to the administration by qualified personnel.
3.5 Capacity and Voluntariness
The Patient affirms that he/she (i) is at least 18 years of age or otherwise legally competent, OR is represented by an Authorized Representative whose authority documentation is attached hereto as Exhibit A; (ii) is not under duress or undue influence; and (iii) has had adequate opportunity to ask questions and receive satisfactory answers.
3.6 Right to Withdraw Consent
The Patient may revoke this Consent in writing at any time prior to commencement of the Procedure without penalty, except for charges already incurred. In emergent or intraoperative situations, withdrawal shall be subject to reasonable limitations necessary to preserve life or prevent serious harm.
3.7 Financial Responsibility
The Patient remains financially responsible for all charges not covered by insurance, including deductibles, co-payments, or non-covered services. The Provider may bill the Patient directly or assign billing rights to the Facility or third-party payers.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider Representation. The Provider represents that it:
a. Holds all licenses and privileges required under Tennessee law;
b. Maintains professional liability insurance meeting or exceeding statutory malpractice limits; and
c. Will perform the Procedure in accordance with prevailing professional standards.
4.2 Patient Representation. The Patient represents that:
a. All medical history disclosed is accurate and complete to the best of the Patient’s knowledge;
b. The Patient has received and reviewed the Provider’s Notice of Privacy Practices; and
c. No promise or guarantee of a specific outcome has been made.
4.3 Survival. The representations and warranties set forth in this Section shall survive completion of the Procedure for the maximum period permitted by Applicable Law.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants. The Patient shall:
a. Follow pre-operative and post-operative instructions;
b. Promptly report unexpected or worsening symptoms; and
c. Make all scheduled follow-up appointments.
5.2 Provider Covenants. The Provider shall:
a. Document all disclosures in the medical record;
b. Maintain confidentiality of Protected Information; and
c. Notify the Patient of any materially new information affecting the risk-benefit calculus.
6. DEFAULT & REMEDIES
6.1 Patient Default. Failure to adhere to Section 5.1 may release the Provider from further non-emergent treatment obligations and may adversely impact outcome warranties, if any.
6.2 Provider Default. Material breach of professional duties entitles the Patient to pursue statutory and common-law remedies, subject to the limitations in Section 7.
7. RISK ALLOCATION
7.1 Indemnification. The Patient (or Authorized Representative) shall indemnify and hold harmless the Provider from liability arising out of the Patient’s material misrepresentation of medical history or non-compliance with medical instructions, except to the extent caused by Provider negligence or willful misconduct (“Informed-Consent Protection”).
7.2 Limitation of Liability. Nothing herein limits any party’s liability for gross negligence or intentional wrongdoing. Monetary damages for Provider’s professional negligence are subject to the caps on noneconomic damages set forth in Tennessee malpractice statutes, as amended from time to time (“Malpractice Limits”).
7.3 Force Majeure. Neither party shall be liable for delay or failure to perform due to events beyond reasonable control, including natural disasters, civil unrest, or governmental actions rendering performance illegal or impossible.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Consent shall be governed by the internal laws of the State of Tennessee without regard to conflicts-of-law principles (“state_medical_law”).
8.2 Forum Selection. The parties irrevocably submit to the exclusive jurisdiction of the state courts located in [COUNTY], Tennessee (“state_court”) for any litigation arising from or related to this Consent.
8.3 Arbitration (Optional). At the election of either party, any dispute otherwise subject to judicial resolution may be submitted to binding arbitration in accordance with the Tennessee Uniform Arbitration Act. Election must be made in writing within thirty (30) days after service of a complaint.
8.4 Jury Waiver. Nothing herein shall be construed as a waiver of any party’s constitutional right to a trial by jury except where arbitration is properly invoked.
8.5 Injunctive Relief. The parties acknowledge that equitable relief may be necessary to protect confidential medical information; any request for such relief shall be narrowly tailored to the legitimate privacy interests at stake.
9. GENERAL PROVISIONS
9.1 Amendments. Any modification of this Consent must be in writing and signed by both parties.
9.2 Assignment. This Consent is personal to the Patient and may not be assigned; the Provider may assign billing rights without further consent.
9.3 Severability. If any provision is held invalid, the remainder shall be enforced to the fullest extent permitted.
9.4 Entire Agreement. This Consent, together with any attached exhibits, constitutes the entire agreement regarding the Procedure and supersedes all prior oral or written statements.
9.5 Counterparts & Electronic Signature. This Consent may be executed in multiple counterparts, each of which shall be deemed an original. Electronic signatures shall be valid and enforceable to the same extent as original signatures under Tennessee’s Uniform Electronic Transactions Act.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Consent as of the Effective Date.
PATIENT (or Authorized Representative):
Signature: _____
Name: [PRINT NAME]
Date: _____
Relationship to Patient (if not Patient): ______
PROVIDER:
Signature: _____
Name: [PRINT NAME & CREDENTIALS]
Title: _____
Date: _______
NOTARY (if required):
State of Tennessee, County of ___
On this day of __________, 20, before me, the undersigned Notary Public, personally appeared ____, proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) are subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Notary Public: _____
My Commission Expires: ___
[// GUIDANCE:
1. Attach Exhibit A (copy of healthcare power of attorney or guardianship order) when signed by an Authorized Representative.
2. Attach Exhibit B (Provider’s Notice of Privacy Practices acknowledgment).
3. Retain original in Patient’s permanent medical record for the minimum period mandated by Tennessee record-retention regulations (currently >10 years for adults).]