Surgery Consent Form
A surgery consent form has to evidence a conversation, not replace one. The procedure named, the material risks discussed, the alternatives offered, and anything the patient specifically refuses.
For clinics, practices and healthcare providers.
Material risks means the ones that matter to this patient
Consent law in most jurisdictions has moved from what a reasonable doctor would disclose to what a reasonable *patient* would want to know - which makes a generic risk list insufficient by design.
So this template names the procedure and asks the patient to confirm the specific risks discussed with them, with space for the clinician to record what was said. It also asks explicitly about anything they refuse - blood products, a particular technique, a trainee operating - because a refusal that isn't recorded is a refusal that gets overridden.
A record you can actually rely on
Consent that was given verbally, or on a paper form in a drawer, is consent you cannot produce when it matters. What you need is the wording they agreed to, the answers they gave, and the date - all in one place.
This template collects exactly that, and every submission is stored with its own timestamp.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Nothing shared, nothing tracked
The page carries no analytics, no third-party scripts and no cookie banner - there's nothing to consent to except what you're asking. For a form about consent, that matters.
Make it yours in a minute
Change the wording, drop the questions you don't need, add the ones you do, put your own colour on it. Saving publishes it, and you get a link to paste into your website, your email signature or a message. Responses land in your dashboard and download as a spreadsheet whenever you want them.
What this template asks
- Patient's full name
- Date of birth
- Hospital or record number
- Consultant or surgeon
- Name of the procedure
- Side or site, if applicable
- Planned date
- Type of anaesthetic discussed
- Which risks were explained to you?
- Any risks discussed that are specific to you?
- The alternatives, including doing nothing, were explained to me
- I had the opportunity to ask questions and they were answered
- I understand no particular outcome has been guaranteed
- Blood transfusion, if clinically needed
- A supervised trainee taking part under supervision
- Clinical photography for my records
- Use of anonymised images or tissue for teaching or research
- Is there anything else you specifically refuse?
- I consent to the procedure named above
- I understand I can change my mind at any time before the procedure
- If consenting on the patient's behalf, your name and legal authority
More Healthcare forms
Questions
Can a web form be used for surgical consent?
As a pre-operative record of the discussion and the patient's decisions, many services do. It is not a substitute for the consent conversation or your own governance process - check with your clinical governance lead and indemnifier.
What about the day-of-surgery confirmation?
Keep it. This documents the informed discussion in advance, when the patient has time to read and reconsider; the final confirmation still happens in person.
Is this legal advice?
No. The wording is a practical starting point, not a legal document - have your own adviser check anything you rely on, especially where health, minors or money are involved.
Is a tick box a valid signature?
In many places a clear, dated, affirmative action is accepted, but it depends on your jurisdiction and what you're doing. If you need a drawn signature, print the response and sign it, or take the form as the pre-appointment record.
Can I keep a copy for the person who filled it in?
Yes - they see a confirmation on screen, and you can turn on an email so a copy of each submission lands in your inbox for your records.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your surgery consent form today
Start from this template and change anything you like. Free to begin.