When to use this consent template
Use it whenever you present treatment that carries real risk or has meaningful alternatives. It also covers informed refusal, which is just as important to document. A signed form proves a form was signed. The chart note is what proves a conversation happened: what you explained, what the patient asked, and what they decided.
The parts of a defensible consent note
- The procedure and the diagnosis it treats.
- Risks, benefits, and alternatives, including no treatment, and the risks of no treatment.
- Questions asked and answered, plus any interpreter or teach-back used.
- The decision, and when it's a refusal, the patient's reason in their own words.
- The form signed (or declined) and any witness.
Example informed refusal note
Consent discussion held with patient. Proposed treatment: root canal therapy #19, for symptomatic irreversible pulpitis. Risks discussed: pain or discomfort, tooth or restoration fracture, treatment failure, need for additional treatment. Alternatives discussed: extraction, no treatment. Risks of no treatment: pain or infection, spread of infection, tooth loss. Patient asked questions, all answered; teach-back used. Decision: refused the recommended treatment. Patient stated: "I want to wait until next month." Informed refusal form signed, witnessed by the assistant. Recommendation to be revisited at next visit.