Patient Consent Form for Treatment (West Virginia)

PATIENT CONSENT FORM FOR TREATMENT (WEST VIRGINIA)

Provider / Facility: [____________________________________]
Provider Address: [____________________________________]
Patient Name: [____________________________________]
Date of Birth: [__/__/____]
Medical Record No.: [____________________]
Date of Consent: [__/__/____]
Time: [____:____ ☐ AM ☐ PM]

1. PATIENT IDENTIFICATION AND CAPACITY

2. PROPOSED TREATMENT, PROCEDURE, OR SERVICE

Procedure / Treatment Name: [____________________________________]
Treating Provider(s): [____________________________________]
Assisting Provider(s): [____________________________________]
Anticipated Date/Time: [__/__/____] at [____:____ ☐ AM ☐ PM]
Facility/Location: [____________________________________]

Description in plain language:
[____________________________________________________________]
[____________________________________________________________]

Indication / Reason for Procedure:
[____________________________________________________________]

3. DISCLOSURE OF MATERIAL RISKS

The treating provider has discussed with the patient the following risks, complications, and side effects reasonably associated with the proposed procedure:

4. ALTERNATIVES AND CONSEQUENCES OF NON-TREATMENT

Reasonable Alternatives Discussed:
☐ No treatment / observation
☐ Medication / pharmacologic therapy
☐ Less invasive procedure: [______________________]
☐ More invasive procedure: [______________________]
☐ Referral or second opinion
☐ Other: [______________________]

Reasonably Foreseeable Consequences of Refusing Treatment:
[____________________________________________________________]

5. ANESTHESIA / SEDATION (IF APPLICABLE)

Risks specific to anesthesia have been separately discussed: ☐ Yes ☐ N/A

6. BLOOD PRODUCTS, TISSUE, AND DISPOSAL

☐ Patient consents to administration of blood or blood products if medically indicated.
☐ Patient refuses blood/blood products (religious or personal grounds). Document refusal: [______________________]
☐ Patient consents to retention, examination, or disposal of removed tissue, organs, or specimens consistent with applicable law and facility policy.
☐ Photography/video for medical record, education, or quality purposes: ☐ Consents ☐ Declines

7. MINORS, SURROGATES, AND SPECIAL CONSENT SITUATIONS

8. ADVANCE DIRECTIVES AND CODE STATUS

☐ Patient has an executed Living Will, Medical Power of Attorney, or Combined Advance Directive under W. Va. Code § 16-30-4. Copy on file: ☐ Yes ☐ No
☐ POST (Physician Orders for Scope of Treatment) form on file.
☐ Code status discussed: ☐ Full code ☐ DNR ☐ Limited intervention
☐ Patient declines to provide advance directive information at this time.

9. FINANCIAL DISCLOSURE / CONFLICTS

☐ The provider has disclosed any proprietary interest in entities to which the patient is being referred (W. Va. Code § 30-3-14).
☐ No such interest exists.

10. PATIENT ACKNOWLEDGMENT

The patient (or authorized representative) acknowledges:

• A discussion has occurred with the treating provider regarding the nature, purpose, material risks, expected benefits, and reasonable alternatives to the proposed treatment.
• All questions have been answered to the patient's satisfaction.
• No guarantee or assurance has been made as to the result or outcome.
• The patient may withdraw consent at any time prior to the procedure.

Patient (or Authorized Representative) Signature: [____________________________________]
Printed Name: [____________________________________]
Relationship to Patient (if representative): [____________________________________]
Date / Time: [__/__/____] [____:____ ☐ AM ☐ PM]

Witness Signature: [____________________________________]
Printed Name: [____________________________________]
Date / Time: [__/__/____] [____:____ ☐ AM ☐ PM]

11. PROVIDER ATTESTATION

I have personally discussed the proposed treatment, its material risks, reasonable alternatives, and the consequences of non-treatment with the patient or authorized representative. I have answered the questions presented, and in my professional judgment the patient or representative possesses sufficient information to provide informed consent.

Provider Signature: [____________________________________]
Printed Name / License No.: [____________________________________]
Date / Time: [__/__/____] [____:____ ☐ AM ☐ PM]

SOURCES AND REFERENCES

• W. Va. Code § 55-7B-7 — Medical Professional Liability Act, expert testimony on standard of care.
• W. Va. Code § 16-30-1 et seq. — West Virginia Health Care Decisions Act.
• W. Va. Code § 16-30-3, -4, -7, -8 — Definitions, execution, capacity, surrogate hierarchy.
• W. Va. Code § 2-3-1 — Age of majority.
• W. Va. Code § 16-4-10 — Minor consent for venereal disease care.
• W. Va. Code § 60-6-23 — Consent for substance abuse treatment.
• W. Va. Code § 30-3-14 — Unprofessional conduct; disclosure of proprietary interest.
• Cross v. Trapp, 170 W. Va. 459, 294 S.E.2d 446 (1982) — informed consent.
• West Virginia Center for Health Ethics and Law — advance directive forms and guidance.