INFORMED CONSENT TO MEDICAL TREATMENT AND ACKNOWLEDGMENT OF DISCLOSURE

(Commonwealth of Virginia)

[// GUIDANCE: This template is intentionally comprehensive. Delete inapplicable bracketed options and tailor the scope of treatment, risks, and dispute-resolution selections to the specific clinical context.]

I. DOCUMENT HEADER

1. Effective Date: [DATE]
2. Patient / Authorized Individual: [NAME] (“Patient”)
3. Health Care Provider: [LEGAL NAME OF ENTITY OR PRACTITIONER] (“Provider”)
4. Facility (if different from Provider): [NAME / ADDRESS]
5. Recitals
   5.1. Provider has proposed to perform or supervise the medical procedure(s) and/or course(s) of treatment described herein (collectively, the “Proposed Treatment”).
   5.2. Pursuant to Va. Code Ann. § 54.1-2970 (Informed Consent), Provider is required to obtain voluntary, knowing, and competent consent prior to rendering the Proposed Treatment.
   5.3. Patient (or the undersigned Authorized Individual) desires to provide such consent subject to the terms, risk allocations, and dispute-resolution provisions set forth below.

II. DEFINITIONS

For purposes of this Consent, capitalized terms have the meanings set forth below. Undefined capitalized terms have the meanings ascribed to them by applicable Virginia law.

“Authorized Individual” means the person legally empowered to make health-care decisions for the Patient pursuant to Va. Code Ann. §§ 54.1-2981 et seq. (Virginia Health Care Decisions Act).
“Capacity” means the ability to understand the nature, consequences, and alternatives of the Proposed Treatment and to make and communicate an informed decision.
“Electronic Record” means any electronic sound, symbol, or process attached to or logically associated with this Consent executed or adopted by a party with intent to sign.
“Known Risk” means a potential adverse outcome of the Proposed Treatment that a reasonably prudent provider in Virginia customarily discloses to a patient under similar circumstances.
“Proposed Treatment” has the meaning provided in Recital 5.1 and is further described in Section III.A.

III. OPERATIVE PROVISIONS

A. Description of Proposed Treatment

1. Nature & Purpose: [DETAILED CLINICAL DESCRIPTION].
2. Anticipated Duration: [INSERT TIMEFRAME].
3. Treating Practitioner(s): [NAME(S) & CREDENTIALS].

B. Disclosure of Alternatives

Provider has discussed the medically reasonable alternatives to the Proposed Treatment, including:
• [ALTERNATIVE 1];
• [ALTERNATIVE 2]; and
• the option of refusing all medical intervention.

C. Disclosure of Known & Material Risks

Provider has disclosed, and Patient acknowledges understanding of, the following categories of risk (including the probability and severity where known):
1. Common minor risks: [LIST].
2. Less-common but significant risks: [LIST].
3. Rare but severe risks, including death, paralysis, permanent disability, and/or disfigurement.

D. Questions & Voluntary Consent

Patient confirms the opportunity to ask questions, that all questions have been answered to Patient’s satisfaction, and that consent is given voluntarily and without duress or undue influence.

E. Withdrawal of Consent

Patient may revoke this Consent at any time prior to initiation of the Proposed Treatment by providing oral or written notice to Provider. Upon revocation, Provider will cease non-emergent treatment as soon as clinically feasible.

F. Financial Responsibility

Patient remains responsible for all charges not covered by insurance or third-party payors. [// GUIDANCE: Insert facility-specific financial disclosure language as required by 12 VAC 5-410-370 et seq.]

G. Conditions Precedent

This Consent is effective only if:
1. Patient possesses Capacity at the time of signing, or the signature is by an Authorized Individual; and
2. Provider has made the disclosures required by Section III.B–C.

IV. REPRESENTATIONS & WARRANTIES

1. Provider’s Representations
   a. Provider is duly licensed and in good standing in the Commonwealth of Virginia.
   b. Provider has disclosed all Known Risks and reasonable alternatives in accordance with Va. Code Ann. § 54.1-2970.
2. Patient’s Representations
   a. Patient (or Authorized Individual) possesses Capacity or legal authority to execute this Consent.
   b. All medical history provided to Provider is complete and accurate to the best of Patient’s knowledge.
3. Survival
   The representations and warranties in this Section survive completion of the Proposed Treatment.

V. COVENANTS & RESTRICTIONS

1. Patient Covenants
   a. To comply with pre- and post-treatment instructions.
   b. To promptly inform Provider of any unexpected complications.
2. Provider Covenants
   a. To perform the Proposed Treatment in accordance with the prevailing professional standard of care in Virginia.
   b. To maintain all patient information in compliance with HIPAA and applicable Virginia privacy laws.

VI. DEFAULT & REMEDIES

1. Patient Default: Failure to follow material medical instructions or to satisfy financial obligations after reasonable notice and an opportunity to cure.
2. Provider Default: Material breach of the standard of care or failure to honor representations herein.
3. Remedies
   a. Monetary damages subject to the limitations in Section VII.B.
   b. Equitable relief limited as provided in Section VIII.D.
   c. Recovery of reasonable attorneys’ fees and costs by the prevailing party.

VII. RISK ALLOCATION

A. Indemnification – Informed Consent Protection

To the fullest extent permitted by Virginia law, Patient agrees to indemnify and hold harmless Provider and its employees from claims, damages, liabilities, costs, and expenses (including reasonable attorneys’ fees) arising solely from Known Risks that were (i) disclosed in writing herein and (ii) realized despite adherence to the applicable standard of care, except to the extent such claims arise from Provider’s gross negligence, willful misconduct, or violation of law.

B. Limitation of Liability

Except for intentional misconduct or gross negligence, any damages recoverable from Provider relating to the Proposed Treatment shall not exceed the maximum amount permitted under Va. Code Ann. § 8.01-581.15 (Medical Malpractice Cap), as amended.

C. Insurance

Provider represents that it maintains professional liability insurance consistent with Virginia statutory requirements.

D. Force Majeure

Provider is excused from delays or failures to perform that result from events beyond its reasonable control, including natural disasters, governmental orders, pandemics, or civil unrest, provided Provider exercises commercially reasonable efforts to mitigate the impact.

VIII. DISPUTE RESOLUTION

A. Governing Law

This Consent and any dispute arising hereunder shall be governed by the laws of the Commonwealth of Virginia, without regard to conflict-of-laws principles.

B. Forum Selection

Subject to Section VIII.C, the parties submit to the exclusive jurisdiction of the state courts located in [COUNTY/CITY], Virginia.

C. Arbitration (Optional)

[ ] Checked if elected: Any dispute not resolved informally within thirty (30) days shall be finally settled by binding arbitration administered by the American Arbitration Association in accordance with its Health Care Arbitration Rules then in effect. Judgment on the award may be entered in any court of competent jurisdiction.

D. Jury Waiver

To the extent permitted by Article I, § 11 of the Constitution of Virginia, each party knowingly and voluntarily waives the right to trial by jury for any dispute arising out of or relating to this Consent.

E. Injunctive Relief

Nothing in this Section limits either party’s right to seek provisional or emergency injunctive relief where the legal standard for such relief is met.

IX. GENERAL PROVISIONS

1. Amendment & Waiver: No amendment is effective unless in writing and signed by both parties. A waiver on one occasion is not a waiver on any future occasion.
2. Assignment: Neither party may assign rights or delegate duties without the other’s prior written consent, except Provider may assign to an affiliated entity or successor in interest.
3. Severability: If any provision is held invalid, the remainder shall be enforced to the fullest extent permitted by law.
4. Integration: This document constitutes the entire agreement regarding informed consent for the Proposed Treatment and supersedes all prior oral or written communications.
5. Counterparts; Electronic Signatures: This Consent may be executed in counterparts, each of which is deemed an original. Electronic signatures and Electronic Records are legally binding.
6. Headings: Headings are for convenience only and do not affect interpretation.

X. EXECUTION BLOCK

[// GUIDANCE: Add notary or witness lines only if required by facility policy or special circumstances (e.g., surgical consents for minors).]

CAPACITY & AUTHORITY ATTESTATION

☐ Patient affirms possessing Capacity at the time of execution.
☐ Authorized Individual affirms legal authority under:
☐ Advance Medical Directive
☐ Durable Power of Attorney
☐ Court Order (guardian/conservator)
☐ Statutory surrogate hierarchy (Va. Code Ann. § 54.1-2986)

[// GUIDANCE: Retain executed originals in the Patient’s medical record for a minimum of six (6) years (or longer if required by 18 VAC 85-20-26).]