Informed Consent Sample Forms
Our informed consent sample forms address common patient safety and risk scenarios. Customize them to your practice and your patients to enhance the informed consent process.
Check your state for specific requirements regarding informed consent forms, procedure-specific disclosures, and legal standards for disclosure of risks.
If you have questions or need assistance, contact the Department of Patient Safety at (800) 421-2368 or by email.
Authorization for Use or Disclosure of Health Information
Authorization for Use or Disclosure of Photographs/Images/Films/Videos
Authorization for Use or Disclosure of Psychotherapy Notes
Basic Elements of an Informed Consent Document
Confidentiality Agreement for Employees/Staff/Students/Volunteers/Observers
Consent to Leave Voice or Text Messages
Dental Procedure Informed Consent Document
Off-Label Use of Prescription Drug
Refusal to Consent to Treatment, Medication, or Testing
Temporary Authorization for a Minor Accompanied by Individual Not Parent/Guardian