Patient Consent Form - Treatment

DISCLAIMER (MANDATORY – DO NOT DELETE)
The following document is a model template for educational purposes only and does not constitute legal or medical advice. Use of this template does not create an attorney-client or physician-patient relationship. Vermont and federal requirements governing informed consent and medical malpractice are complex and frequently updated; therefore, a qualified Vermont-licensed attorney and the treating clinician must review, customize, and approve this form before implementation.

PATIENT CONSENT TO TREATMENT AGREEMENT

(Vermont – Comprehensive Informed Consent Form)

I. PURPOSE AND CONSIDERATION

A. Purpose. This Agreement records the informed consent of Patient (or Representative) for the performance of one or more medical treatments, procedures, or services (collectively, "Treatment") by Provider, in compliance with Vermont's informed-consent statute, 12 V.S.A. § 1909, and the Vermont Medical Practice Act, 26 V.S.A. ch. 23.

B. Consideration. In consideration of Provider's agreement to furnish Treatment and related services, the Parties agree to the terms set forth herein.

C. Acknowledgment of Receipt. Patient acknowledges receipt of a copy of this Agreement and that its provisions have been explained in language Patient understands.

II. DEFINITIONS

• "Adverse Event" — Any unanticipated injury or complication arising in connection with Treatment that may require further medical intervention.
• "Capacity" — The ability to understand the nature, risks, benefits, and alternatives of Treatment and to make and communicate a decision, consistent with 18 V.S.A. ch. 231 (Advance Directives for Health Care) and applicable Vermont common law.
• "Confidential Information" — Individually identifiable health information protected under HIPAA (45 C.F.R. pts. 160 & 164) and the Vermont Patient Privilege (12 V.S.A. § 1612).
• "Emergency Condition" — A condition in which delay in Treatment would jeopardize Patient's life, health, or bodily function; consent requirements are excused under 12 V.S.A. § 1909(c).
• "Reasonable Patient Standard" — Vermont's disclosure standard, requiring disclosure of information that a reasonably prudent patient in the Patient's position would consider material to the decision (see Small v. Gifford Mem. Hosp., 133 Vt. 552 (1975); statutory codification at 12 V.S.A. § 1909).

III. OPERATIVE PROVISIONS

A. Disclosure of Treatment Information

Pursuant to 12 V.S.A. § 1909, Provider has disclosed and Patient acknowledges receipt of the following:

B. Description of Treatment

Proposed Treatment: [DESCRIPTION OF PROCEDURE/TREATMENT]
Indication/Diagnosis: [INDICATION]
Anticipated Date(s) of Treatment: [__/__/____]

C. Capacity and Voluntariness

☐ Patient is 18 years of age or older (age of majority — 1 V.S.A. § 173) and has Capacity.
☐ Patient is a minor 12 years of age or older consenting under 18 V.S.A. § 4226 (regulated drug dependence, venereal/STD, or alcoholism), with finding verified by a licensed physician.
☐ Representative is providing consent under a valid advance directive or guardianship under 18 V.S.A. ch. 231.
☐ Consent is given freely, without coercion, after opportunity to ask questions.

D. Special Minor Consent (VT-Specific)

Vermont permits minors aged 12 or older to consent independently to certain treatments under 18 V.S.A. § 4226:

E. Emergency Exception

Per 12 V.S.A. § 1909(c), the informed consent requirement does not apply to emergency Treatment. Provider may proceed without consent where delay would jeopardize life, health, or bodily function and consent cannot reasonably be obtained.

F. Statutory Defenses Acknowledged

Patient acknowledges that under 12 V.S.A. § 1909(a), defenses to an informed-consent claim include: (1) risk too commonly known to require disclosure; (2) Patient's assurance to proceed regardless of risk or refusal to be informed; (3) consent not reasonably possible; (4) a reasonably prudent person in Patient's position would have undergone the Treatment if fully informed.

IV. REPRESENTATIONS AND WARRANTIES

A. Patient/Representative represents accurate disclosure of medical history, medications, allergies, and substance use.
B. Patient/Representative has had adequate time to consider this Agreement and to consult with family or independent counsel.
C. Patient/Representative understands that medicine is not an exact science and no specific result is guaranteed.

V. COVENANTS AND PATIENT RESPONSIBILITIES

• Follow pre- and post-Treatment instructions provided by Provider.
• Disclose any change in medical condition prior to Treatment.
• Comply with follow-up appointment schedule.
• Promptly report any Adverse Event.

VI. RISK ALLOCATION

A. No Guarantee of Outcome. Provider has made no representation regarding the outcome of Treatment.

B. Insurance and Coverage. Patient is responsible for charges not covered by insurance, subject to Vermont billing-disclosure laws.

C. Malpractice Standard. Nothing in this Agreement waives Patient's rights under 12 V.S.A. ch. 215 (medical malpractice actions) or limits Provider's standard-of-care obligations.

VII. CONFIDENTIALITY (HIPAA AND VERMONT LAW)

Provider shall protect Confidential Information consistent with HIPAA (45 C.F.R. pts. 160 & 164) and the Vermont Patient Privilege (12 V.S.A. § 1612). Patient may withdraw authorization for specific disclosures by written notice, except where disclosure has already been made or is required by law.

VIII. DISPUTE RESOLUTION

A. Good-Faith Resolution. The Parties will first attempt good-faith informal resolution of any dispute.

B. Mediation. Either Party may demand mediation in [COUNTY, VT] before litigation.

C. Forum. Subject to applicable Vermont law, any litigation shall be brought in the Vermont Superior Court for [COUNTY] County.

IX. GENERAL PROVISIONS

A. Governing Law. Vermont law governs without regard to conflict-of-laws principles.
B. Severability. If any provision is unenforceable, the remainder shall remain in effect.
C. Right to Revoke. Patient may revoke this consent at any time prior to Treatment by written or oral notice to Provider; revocation does not affect Treatment already commenced where withdrawal would endanger Patient.
D. Entire Agreement. This Agreement, together with attached disclosure forms, constitutes the entire informed-consent record.
E. Language and Interpretation. Provider shall provide qualified interpretation services as required by Title VI of the Civil Rights Act and applicable Vermont law.

X. SIGNATURES

Clinician Attestation: I have personally explained the nature, purpose, risks, benefits, and alternatives of the proposed Treatment to Patient/Representative; answered all questions to the best of my ability; and confirmed Patient/Representative's understanding and voluntary consent in accordance with 12 V.S.A. § 1909.

Clinician Printed Name: [________________________________]
VT Medical License No.: [____________]

SOURCES AND REFERENCES

• 12 V.S.A. § 1909 — https://legislature.vermont.gov/statutes/section/12/081/01909
• 18 V.S.A. § 4226 — https://legislature.vermont.gov/statutes/section/18/084/04226
• 18 V.S.A. ch. 231 (Advance Directives) — https://legislature.vermont.gov/statutes/chapter/18/231
• 26 V.S.A. ch. 23 (Medical Practice Act) — https://legislature.vermont.gov/statutes/fullchapter/26/023
• Small v. Gifford Mem. Hosp., 133 Vt. 552 (1975) (verify reasonable-patient standard)