INFORMED CONSENT FOR MEDICAL TREATMENT
State of Wisconsin
TABLE OF CONTENTS
- Document Header .............................................. 2
- Definitions ............................................................ 2
- Operative Provisions (Disclosure & Acknowledgment) ......... 4
- Representations & Warranties ..................................... 6
- Covenants & Restrictions .......................................... 7
- Revocation; Termination ............................................ 8
- Risk Allocation ......................................................... 9
- Dispute Resolution .................................................... 10
- General Provisions .................................................... 11
- Execution Block ..................................................... 12
[// GUIDANCE: Section numbers will auto-update in most word processors when using a built-in TOC. Confirm accuracy after final edits.]
1. DOCUMENT HEADER
1.1 Title. Informed Consent for Medical Treatment (“Consent”).
1.2 Parties. This Consent is entered into as of [EFFECTIVE DATE] (“Effective Date”) by and between:
(a) [PATIENT LEGAL NAME], date of birth [DOB], residing at [ADDRESS] (“Patient,” which term includes any Authorized Representative as defined below); and
(b) [PROVIDER LEGAL NAME], a Wisconsin-licensed [PHYSICIAN / ADVANCED PRACTICE PROVIDER / HOSPITAL] (“Provider”).
1.3 Recitals.
A. Provider has recommended that Patient undergo the medical treatment described herein (“Treatment”).
B. Wisconsin law, including Wis. Stat. § 448.30, requires Provider to secure Patient’s informed consent prior to Treatment.
C. Patient desires to provide such consent under the terms and conditions of this Consent.
2. DEFINITIONS
Unless the context clearly indicates otherwise, the following terms have the meanings set forth below and apply equally to singular and plural forms. Alphabetical order is used for ease of reference.
“Alternative Treatment” – Any medically reasonable option to the proposed Treatment, including the option of no treatment.
“Authorized Representative” – An individual authorized under Wis. Stat. chs. 54, 155, or 252 (as applicable) to make healthcare decisions on behalf of an incapacitated Patient, including but not limited to a healthcare agent under a power of attorney, legal guardian, or parent of a minor.
“Capacity” – The ability to understand the proposed Treatment, appreciate its reasonably foreseeable risks and benefits, deliberate regarding the choices presented, and communicate a decision, consistent with Wis. Stat. § 155.01(4).
“Informed Consent” – A decision by Patient (or Authorized Representative) that is: (i) voluntary; (ii) made with Capacity; and (iii) based on sufficient information provided in compliance with Wis. Stat. § 448.30.
“Material Risk” – A risk that a reasonable patient in Patient’s position would likely consider significant when deciding whether to consent to Treatment.
“Provider Personnel” – Provider’s employees, contractors, medical staff, and credentialed individuals involved in Patient’s care.
“Treatment” – The specific medical, surgical, diagnostic, or therapeutic procedure(s) described in Section 3.1.
[// GUIDANCE: Add any procedure-specific definitions (e.g., “Anesthesia,” “Blood Products”) as needed.]
3. OPERATIVE PROVISIONS (DISCLOSURE & ACKNOWLEDGMENT)
3.1 Description of Treatment.
Provider proposes to perform: [DESCRIPTION OF PROCEDURE/TREATMENT], including any reasonably related or ancillary services (e.g., pre-operative testing, anesthesia, post-operative care).
3.2 Required Disclosures. Provider has disclosed, and Patient acknowledges receipt and comprehension of, information covering each of the following subject matters, consistent with Wis. Stat. § 448.30:
(a) The Patient’s diagnosis and the nature/purpose of the Treatment;
(b) The Material Risks and potential complications, including [CUSTOMIZE: e.g., bleeding, infection, adverse drug reaction, nerve injury];
(c) The Material Benefits anticipated;
(d) Alternative Treatment options and their respective risks and benefits, including the reasonably foreseeable results of declining all treatment; and
(e) The identity, credentials, and role of all Provider Personnel materially participating in Treatment.
3.3 Questions & Answers.
Patient (or Authorized Representative) has had the opportunity to ask questions, received satisfactory answers, and requires no additional information.
3.4 Voluntariness.
Patient affirms that consent is given voluntarily, free from coercion or undue influence.
3.5 Capacity Attestation.
(a) Patient presently possesses Capacity.
(b) If Patient lacks Capacity or is a minor, the signatory below is the Authorized Representative, and evidence of authority is attached as Exhibit A.
3.6 Authorization for Ancillary Services.
Patient authorizes Provider to administer pharmaceuticals, anesthesia, radiology, pathology, laboratory testing, and other ancillary services reasonably necessary for the safe and effective delivery of Treatment, subject to the limitations in this Consent.
3.7 Use of Blood Products [DELETE IF INAPPLICABLE].
Provider may administer blood or blood products if, in Provider’s professional judgment, such intervention is medically necessary to prevent serious harm or death. Patient [CHECK ONE]: ☐ consents ☐ refuses to the administration of blood products.
3.8 Photography, Recording, & Telemedicine [OPTIONAL].
(a) Patient authorizes medical photography or recording solely for treatment or educational purposes, with identifying features removed unless additional written consent is provided.
(b) If telemedicine is utilized, Patient consents to the electronic transmission of medical information, acknowledging that security measures are in place but absolute protection cannot be guaranteed.
3.9 HIPAA Notice.
Patient acknowledges receipt of Provider’s Notice of Privacy Practices pursuant to 45 C.F.R. § 164.520.
4. REPRESENTATIONS & WARRANTIES
4.1 Provider Warranties.
(a) Provider is duly licensed and in good standing in the State of Wisconsin.
(b) Provider will perform Treatment in accordance with the prevailing professional standard of care.
(c) Provider has no known conflicts of interest that would materially affect the advice or care rendered.
4.2 Patient Representations.
(a) Patient has provided complete and accurate medical history, allergies, medications, and prior adverse reactions.
(b) Patient is not relying on any statement or guarantee regarding specific outcomes.
(c) Patient understands that results depend upon individual medical circumstances and that no particular outcome can be assured.
4.3 Survival.
The representations and warranties in this Section 4 survive completion of Treatment for the applicable statute-of-limitations period.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants.
(a) Compliance with Pre- and Post-Treatment instructions.
(b) Timely disclosure of any change in health status or adverse reaction.
(c) Payment of all charges in accordance with Provider’s financial policies.
5.2 Provider Covenants.
(a) Maintain professional liability insurance in the minimum amounts required by Wis. Admin. Code ch. Med 11.
(b) Comply with all applicable federal, state, and local laws, rules, and regulations governing Patient care and confidentiality.
6. REVOCATION; TERMINATION
6.1 Right to Revoke.
Patient may revoke this Consent at any time prior to commencement of Treatment by delivering written or verbal notice to Provider. Revocation shall not affect (i) actions already taken in reliance on this Consent, or (ii) emergency measures reasonably necessary to preserve life or prevent serious harm.
6.2 Provider Withdrawal.
Provider may decline or discontinue Treatment if continuing would, in Provider’s professional judgment, violate ethical obligations or applicable law. Provider will use reasonable efforts to refer Patient for alternative care.
7. RISK ALLOCATION
7.1 Indemnification (Informed Consent Protection).
To the fullest extent permitted by law, Patient shall indemnify and hold harmless Provider and Provider Personnel from third-party claims arising out of Patient’s breach of Section 5.1 or misuse of medical equipment provided for post-Treatment care, except to the extent caused by Provider’s negligence or willful misconduct.
[// GUIDANCE: This clause is narrow by design and should not be construed to waive malpractice rights under Wis. Stat. ch. 655.]
7.2 Limitation of Liability.
Any non-economic damages recoverable against Provider arising from Treatment are subject to the caps set forth in Wis. Stat. § 893.55(4)(d) (currently $750,000), as amended from time to time (“Malpractice Limits”). This Section 7.2 does not limit economic or punitive damages where recoverable by law.
7.3 Insurance.
Provider maintains professional liability coverage meeting or exceeding Wis. Stat. § 655.23(3)(a).
7.4 Force Majeure.
Neither party shall be liable for delays or failures to perform that are caused by acts of God, war, terrorism, government orders, labor disputes, pandemics, or other events beyond the reasonable control of the affected party, excluding payment obligations.
8. DISPUTE RESOLUTION
8.1 Governing Law.
This Consent and any dispute arising hereunder shall be governed by the laws of the State of Wisconsin, without regard to its choice-of-law rules.
8.2 Forum Selection.
Exclusive jurisdiction and venue lie with the state courts of [COUNTY], Wisconsin (“State Court”), subject to Section 8.3.
8.3 Optional Arbitration.
(a) Either party may elect binding arbitration by providing written notice within 60 days after a claim accrues.
(b) Arbitration shall be conducted pursuant to Wis. Stat. ch. 788 and the Commercial Arbitration Rules of the American Arbitration Association.
(c) Costs shall be allocated by the arbitrator in accordance with law; the arbitrator may award any remedy available in State Court except injunctive relief beyond that permitted in Section 8.4.
8.4 Injunctive Relief.
A party may seek temporary or preliminary injunctive relief in State Court solely to: (i) enforce confidentiality or HIPAA-protected information, or (ii) preserve the status quo pending arbitration.
8.5 Jury Right Preserved.
Nothing in this Consent shall constitute a waiver of Patient’s constitutional right to a trial by jury in State Court should arbitration not be elected.
9. GENERAL PROVISIONS
9.1 Amendment and Waiver.
No amendment or waiver of any provision of this Consent is effective unless in writing and signed by both parties. A waiver on one occasion is not a waiver of any subsequent breach.
9.2 Assignment.
Neither party may assign or delegate its rights or obligations under this Consent without the prior written consent of the other, except Provider may assign to a successor practice entity without Patient consent.
9.3 Severability.
If any provision of this Consent is held invalid or unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to achieve the original intent.
9.4 Integration.
This Consent constitutes the entire understanding between the parties regarding its subject matter and supersedes all prior oral or written communications.
9.5 Counterparts; Electronic Signatures.
This Consent may be executed in counterparts, each of which is deemed an original, and all of which constitute one and the same instrument. Signatures transmitted by facsimile, PDF, or secure electronic platform (e.g., DocuSign) shall be deemed originals.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the undersigned have executed this Consent as of the Effective Date.
PROVIDER
Authorized Signature
Name: [PRINT NAME]
Title: [PHYSICIAN / PRACTICE ADMINISTRATOR]
Date: _______
PATIENT
☐ Patient with Capacity ☐ Authorized Representative
Signature
Name: [PRINT NAME]
Relationship to Patient (if Representative): ____
Date: _______
[// GUIDANCE: Attach documentation of representative authority (e.g., POA, guardianship letters) as Exhibit A.]
WITNESS [OPTIONAL IF NOT REQUIRED]
Signature of Witness
Name: [PRINT NAME]
Date: _______
NOTARY ACKNOWLEDGMENT [USE ONLY IF REQUIRED BY FACILITY POLICY]
State of Wisconsin County of [_]
Subscribed and sworn before me on _/_/20_, by ___.
Signature of Notary Public
My commission expires: _____
[END OF DOCUMENT]