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 Device

Off-Label Use of Prescription Drug

Online Communication

Refusal to Consent to Treatment, Medication, or Testing

Telehealth Informed Consent

Temporary Authorization for a Minor Accompanied by Individual Not Parent/Guardian

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