PATIENT CONSENT FORM – TREATMENT

State of Utah

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

This Patient Consent Form for Treatment (“Agreement”) is made effective as of [EFFECTIVE DATE] (the “Effective Date”) by and between:

• [PATIENT NAME], date of birth [MM/DD/YYYY], residing at [ADDRESS] (“Patient”); and
• [PRACTICE NAME], a Utah professional corporation with its principal place of business at [ADDRESS] (“Provider”).

Recitals

A. Patient seeks to receive certain medical services from Provider.
B. Provider is willing to render such services subject to Patient’s informed, voluntary, and competent consent.
C. The parties enter into this Agreement in consideration of the mutual promises herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged.

2. DEFINITIONS

For purposes of this Agreement, the following terms shall have the meanings set forth below:

“Authorized Representative” – A person legally empowered to act on behalf of Patient, including but not limited to a parent, guardian, or individual holding a valid health-care power of attorney.

“Capacity” – Patient’s ability, under applicable Utah law, to understand the nature and consequences of the proposed Treatment and to make a knowing and voluntary decision.

“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations.

“Known Complications” – Those risks and side effects customarily associated with the Treatment, as disclosed by Provider.

“Treatment” – Any medical, surgical, diagnostic, or therapeutic procedure, service, medication, or course of care described in Section 3.2.

“Utah Malpractice Limits” – Any statutory or regulatory limitations on damages or liability applicable to health-care providers under Utah law, as amended from time to time.

[// GUIDANCE: Add additional defined terms as needed for specialized therapies.]

3. OPERATIVE PROVISIONS

3.1 Consent to Treatment.
Patient hereby voluntarily and knowingly consents to receive the Treatment from Provider, including any ancillary services reasonably related thereto.

3.2 Description of Proposed Treatment.
Provider has explained, and Patient acknowledges receipt and understanding of, the following:
a. Nature and purpose of the proposed Treatment: [INSERT DESCRIPTION]
b. Expected benefits and anticipated outcome.
c. Reasonable alternatives, including the option of no treatment.
d. Material risks, side effects, and Known Complications, including their probabilities where known.
e. Name(s) of individual(s) performing significant portions of the Treatment.
f. Estimated recovery time and post-Treatment requirements.

[// GUIDANCE: In Utah, disclosure must meet the “reasonable patient” standard—i.e., information a reasonably prudent patient would need to make an informed decision.]

3.3 Voluntary Decision & Capacity.
Patient affirms (i) possessing Capacity, (ii) having had adequate time to ask questions, and (iii) that no coercion or undue influence was exercised. If Patient lacks Capacity, the Authorized Representative executing this Agreement affirms legal authority to consent on Patient’s behalf.

3.4 Right to Withdraw.
Patient may revoke this consent at any time prior to the commencement of the Treatment without penalty, except for reasonable charges incurred up to the time of revocation.

3.5 Financial Responsibility.
Patient remains responsible for all charges not paid by insurance or third-party payors. Provider may bill Patient directly for deductibles, co-payments, and non-covered services.

3.6 Assignment of Benefits.
Patient hereby assigns to Provider any insurance or health-plan benefits payable for the Treatment, authorizing direct payment to Provider.

3.7 Photographs & Recordings.
Patient consents to the taking and use of photographs or recordings solely for (i) medical documentation, (ii) treatment planning, or (iii) Provider’s internal quality assurance, subject to HIPAA.

3.8 Disposal of Tissue & Specimens.
Unless otherwise required by law or expressly requested by Patient in writing, Provider may dispose of any removed tissue, fluid, or specimen in a customary medical manner.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient Representations.
Patient (or Authorized Representative):
a. Has provided accurate, complete medical and personal information;
b. Understands that results cannot be guaranteed;
c. Acknowledges receipt of Utah-mandated disclosures; and
d. Agrees to follow Provider’s pre- and post-Treatment instructions.

4.2 Provider Representations.
Provider represents that it (i) is duly licensed in the State of Utah, (ii) will perform the Treatment in accordance with the applicable standard of care, and (iii) maintains professional liability insurance meeting or exceeding Utah Malpractice Limits.

4.3 Survival.
The representations and warranties in this Section shall survive completion of the Treatment for the period permitted under Utah’s statute of repose for medical malpractice claims.

5. COVENANTS & RESTRICTIONS

5.1 Patient Covenants.
Patient shall:
a. Comply with all medical instructions;
b. Promptly inform Provider of any adverse reactions; and
c. Keep all scheduled follow-up appointments.

5.2 Provider Covenants.
Provider shall:
a. Maintain confidentiality of Patient’s records consistent with HIPAA;
b. Provide post-Treatment care instructions; and
c. Promptly notify Patient of any material change in the Treatment plan.

6. DEFAULT & REMEDIES

6.1 Patient Withdrawal After Commencement.
If Patient withdraws consent after Treatment has begun, Provider may halt Treatment when medically safe and Patient shall remain liable for services rendered.

6.2 Breach by Provider.
In the event of Provider’s material breach of this Agreement or deviation from the applicable standard of care, Patient retains all rights and remedies available under Utah law.

6.3 Attorney Fees.
In any action arising out of or relating to this Agreement, the prevailing party shall be entitled to reasonable attorney fees and costs.

7. RISK ALLOCATION

7.1 Indemnification – Informed Consent Protection.
Patient shall indemnify and hold harmless Provider, to the fullest extent permitted by law and subject to Utah Malpractice Limits, from any claim arising out of (i) Patient’s misrepresentation of medical history or Capacity, or (ii) unauthorized use or disclosure of medical information by Patient.

[// GUIDANCE: Utah law prohibits contractually waiving Provider’s liability for negligence. The above clause is narrowly drafted to avoid impermissible waiver yet provide defensive protection.]

7.2 Limitation of Liability.
Provider’s liability, if any, shall not exceed the limitations set forth in Utah Malpractice Limits; nothing herein restricts Patient’s rights beyond those statutory caps.

7.3 Force Majeure.
Neither party shall be liable for delays or failure to perform caused by events beyond reasonable control, except that Patient’s payment obligations for services rendered shall not be excused.

8. DISPUTE RESOLUTION

8.1 Governing Law.
This Agreement shall be governed by the substantive laws of the State of Utah, without regard to its conflict-of-laws principles.

8.2 Forum Selection.
Exclusive venue for any action shall lie in the state courts of competent jurisdiction located in [COUNTY], Utah.

8.3 Optional Binding Arbitration.
☐ Check to Opt-In – The parties agree to submit disputes to binding arbitration administered by [ARBITRATION SERVICE] in accordance with its healthcare rules. Judgment on the award may be entered in any court of competent jurisdiction.
If this box is not checked, disputes shall be resolved in accordance with Sections 8.1 and 8.2.

8.4 Jury Trial.
Nothing in this Agreement constitutes a waiver of either party’s constitutional right to a jury trial.

8.5 Injunctive Relief.
The parties acknowledge that monetary damages may not fully remedy breach of confidentiality obligations; therefore, limited injunctive relief may be sought, provided such relief does not restrict Patient’s access to emergency medical care.

9. GENERAL PROVISIONS

9.1 Amendments; Waivers.
Any amendment or waiver must be in writing and signed by both parties.

9.2 Assignment.
Neither party may assign its rights or delegate its duties without the prior written consent of the other, except that Provider may assign for purposes of billing or corporate reorganization.

9.3 Successors & Assigns.
This Agreement binds and benefits the parties and their respective successors and permitted assigns.

9.4 Severability.
If any provision is held unenforceable, the remaining provisions shall remain in full force, and the unenforceable provision shall be modified to the minimum extent necessary to render it enforceable.

9.5 Integration.
This Agreement constitutes the entire understanding between the parties regarding its subject matter and supersedes all prior oral or written communications.

9.6 Counterparts; Electronic Signatures.
This Agreement may be executed in counterparts, each deemed an original, and electronic signatures shall be valid and binding.

10. EXECUTION BLOCK

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

[// GUIDANCE:
1. For minors or incapacitated adults, add a second signature line for the Authorized Representative and include evidence of authority (e.g., guardianship papers).
2. Utah does not require notarization of medical consent forms; however, Provider may add a witness signature for additional evidentiary value.
]

End of Document