This medical liability waiver form covers the following:
I, [Patient.FirstName] [Patient.LastName] (“Patient”), authorize [Sender.Company] to seek, obtain, and consent for (Treatment) as a licensed medical or healthcare professional deems necessary. This authorization is for the period I am in the care of (Doctor.Name), my (Doctor.Position) and is effective for (Period) until I revoke it.
We, [Guardian1.FirstName] [Guardian1.LastName] and [Guardian2.FirstName] [Guardian2.LastName] being the parents/guardians of (UnderagePatient.Name) (“Patient”), authorize [Sender.Company] to see, obtain, and consent to (Treatment) as a licensed healthcare or medical professional deems necessary. This authorization is for the period (UnderageChild.Name) is in the care of (Doctor.Name). This individual is their (Doctor.Position) and if effective until we revoke it. I understand that by signing this document, its terms also apply to the underage Patient on whose behalf I am signing.
You can customize this form for underage children and of age persons. We also recommend filling in the company details, like the name and treatment plan. This section ensures the correct information is on the form for the Patient to know.
This medical liability waiver form sample suggests separate sections for the Patient to complete. This data is critical information when receiving the Patient’s consent.
Patient Full Name: [Patient.FirstName] [Patient.LastName]
Address: [Patient.StreetAddress] [Patient.City] [Patient.State] [Patient.PostalCode]
Date of Birth: __/__/____ Age: ____
Health Conditions (e.g., Asthma, Diabetes, etc.):
Allergies (e.g., Medications, Food):
Date of Last Tetanus Shot/Booster:
Preferred Medical Facility:
Complete the below information should the Patient be underage or need Guardian Consent:
Parent/Guardian Name: [Guardian1.FirstName] [Guardian1.LastName]
Address: [Guardian1.StreetAddress] [Guardian1.City] [Guardian1.State] [Guardian1.PostalCode]
Phone Number (H): [Guardian1.Phone]
Emergency Contact Name:
This section is optional for form liability waiver form, wherever you may include it for getting medical consent. You may add the full scope of the treatment plan or outline the treatments you’ll start with.
The below schedule is the planned treatments devised for the Patient:
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My Doctor has explained to me the following conditions exist in my case:
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This box requires adding any of the Treatment’s complications, risks, or benefits. While you’ll have a section covering you generally, it’s better to add information on what you know might happen. This knowledge is a significant part of the Patient giving proper consent.
I understand and accept that medical and surgical treatments and procedures involve some risks. These risks include, without limitation, allergic reactions, blood clots, bleeding, scarring, infections, and adverse side effects of drugs.
I am aware that in the practice of medicine, other unexpected complications and risks my Doctor didn’t discuss with me might occur. I understand the proposed treatments might reveal unforeseen conditions. These conditions might result in the processed treatments changing.
I understand what my Doctor and other medical practitioners discussed with me. I further understand the contents of this medical liability waiver form. I received the opportunity to ask questions and receive satisfactory answers.
I authorize my physician, hospital, or healthcare provider to release and furnish the required parties with medical records or other information about the above-listed condition. But, I understand that the institution will keep all confidential information private.
I am voluntarily participating in this Treatment. I assume all known and unknown risks of my participation in these treatments and procedures. I further agree to indemnify, defend, and hold the medical or healthcare institute and its practitioners harmless against all claims and suits of action against liability, compensation, damages, or otherwise brought to me, including attorney fees and related costs.
Having read this form and talked with the physicians, my signature below signifies that I give my authorization and consent. This consent is for my Doctor and their associates, assisted by medical center personnel and other trained persons, and with the presence of observers, to perform the treatments and procedures described above.
Our form template is customizable, and if you want to print it, you can download it as a PDF. You can also send it to the Patient for them to fill out and add their signature.