Informed Consent Acknowledgement
A structured consent record: understanding confirmed, questions invited, signed and dated.
6 questions · 1 page · about 4 minutes to answer · fully editable after you start
Consent is a conversation, but the record of it needs structure: what was explained, that questions were invited and answered, and a signature with the date. This form documents each element separately – risks, alternatives, the right to withdraw – so the acknowledgement is specific rather than a single blanket checkbox.
Pair it with your procedure-specific information sheet and keep one response per patient per procedure. Thisys stores the drawn signature with the response, and the consent timestamp is recorded automatically.
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Consent acknowledgement
This form records that you have been given information about a procedure or treatment and agree to go ahead. Please read each statement carefully, and ask a member of the team before you sign if anything is unclear. It takes about 4 minutes. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.Patient full name*
Q2.Procedure or treatment being consented to*
Q3.Please confirm each statement.*
| I confirm | I need more information | |
|---|---|---|
| The procedure and its purpose were explained to me | ||
| Risks and side effects were explained | ||
| Alternatives were discussed | ||
| I know I can withdraw consent at any time |
Q4.Questions you still want answered before proceeding (write None if none)*
Q5.Date of consent*
Q6.Patient signature*
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