What is the procedure consent form template?
Consent is a conversation, and the form is the record of it. This template captures what a clinician actually discussed with a patient before a procedure — why it's recommended, what it involves, the common and serious risks, the alternatives including no treatment — and then the patient's signed agreement and the clinician's own confirmation.
The risk and alternatives fields are free text so you can record the words you used, not a generic list. The form handles consent given by a parent, guardian or legal representative (asking their name and relationship), records whether an interpreter was used and whether written information was given, and keeps the patient's questions and the answers given.
The finished record, with both signatures, is saved as a PDF in your FileIt vault.
- Best for
- Clinics, day-surgery units, dentists, dermatologists and minor-procedure services
- Filled in by
- The clinician with the patient, who signs on screen
- Time to complete
- About 10 minutes
- Includes
- Free-text risks and alternatives, representative consent, interpreter record, two signatures
Who uses a procedure consent form?
- Minor surgery such as lesion excision or joint injection
- Endoscopy or other day-case procedures
- Dental extractions or implants
- Consent given by a parent for a child's procedure
- Recording consent with an interpreter present
- Outpatient procedures where a paper form keeps going missing
Questions on this procedure consent form
31 questions over 4 pages · includes signature, conditional questions, multiple pages, consent checkbox.
1 Patient & procedure
- Patient name*
- Date of birth*
- Patient ID / record number
- Procedure*
- Site / side* Left · Right · Both sides · Not applicable
- Planned date
- Why the procedure is recommended*
- What the procedure involves
- Anaesthesia or sedation* None · Local anaesthetic · Sedation · Regional anaesthetic · General anaesthetic
2 Risks & alternatives
- Common or expected side effects discussed*
- Serious or rare risks discussed*
- Alternatives discussed, including no treatment*
- Any additional procedure that may become necessary
- Blood transfusion, if needed Accepts · Declines · Not applicable
- Written information given to the patient?
- Leaflet title or reference asked only when it applies
- Was an interpreter used?
- Interpreter name and language asked only when it applies
3 Patient consent
- Consent given by* The patient · Parent or guardian · Legal representative
- Name of person giving consent* asked only when it applies
- Relationship to the patient* asked only when it applies
- Did the patient have questions?
- Questions asked and answers given asked only when it applies
- Understanding*
- Consent*
- Signature of patient or person giving consent*
- Date*
4 Clinician confirmation
- Clinician name*
- Role and registration number
- Clinician statement*
- Clinician signature*
The procedure consent form, page by page
1 Patient & procedure
Patient name, date of birth and record number; the procedure, site or side, planned date; why it's recommended and what it involves; and the type of anaesthesia or sedation.
2 Risks & alternatives
Free-text fields for the common side effects and the serious or rare risks discussed, the alternatives (including no treatment) and any additional procedure the patient agrees to in advance. It records the patient's decision on blood transfusion if needed, whether written information was given (and which leaflet), and whether an interpreter was used.
3 Patient consent
Who is giving consent — the patient, a parent or guardian, or a legal representative, with their name and relationship when it isn't the patient. Questions asked and the answers given are recorded. The person consenting confirms their understanding and agreement, signs and dates.
4 Clinician confirmation
The clinician's name, role and registration number, a statement that they explained the procedure and believe it was understood, and their signature.
Make the template yours
- Pre-fill the procedure, risks and alternatives in a copy of the form for each procedure you do often
- Add a second confirmation page for consent re-confirmed on the day
- Remove the blood transfusion question for procedures where it never applies
- Add a question on tissue or photographs being kept for teaching
- File consent forms into each patient's folder in your vault
- Have the statements reviewed against your regulator's consent guidance
Tips for a better procedure consent form
- Write the risks in the words you used with the patient, not jargon
- Always record alternatives, including doing nothing
- Give the patient time between the conversation and signing when you can
- Reconfirm consent on the day if circumstances have changed
- A signature records consent; it doesn't replace the conversation
Every response becomes a PDF in your vault
The completed consent, with the patient's and clinician's signatures, is saved as a PDF in your FileIt vault, and you're notified by email. The patient can receive a copy.
Use the Responses table to see which upcoming procedures have consent on file.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Procedure consent form: frequently asked questions
Is this procedure consent form free?
Yes. It's included in the Forms app on every FileIt account, including the free plan.
Can a parent or guardian sign?
Yes. Choose who is giving consent and the form asks for their name and relationship to the patient.
Does it list risks for me?
No. Risks and alternatives are free text so you can record exactly what you discussed for that procedure.
Can I make a version for a specific procedure?
Yes. Duplicate the form and pre-fill the help text or add paragraphs with that procedure's standard information.
Does the clinician sign too?
Yes. The last page has a clinician statement and signature.
Is it legally valid consent?
Valid consent depends on the discussion, capacity and local law, not the form alone. Have the wording reviewed for your setting.