Medical Liability Waiver Form

​[Patient.FirstName][Patient.LastName], [Patient.Company]​

​[Patient.StreetAddress][Patient.City][Patient.State][Patient.PostalCode]​

​[Patient.Phone][Patient.Email]​

​[Document.CreatedDate]​

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.

Patient Information

Patient Full Name: [Patient.FirstName][Patient.LastName]​

Address: [Patient.StreetAddress][Patient.City][Patient.State][Patient.PostalCode]​

Date of Birth: __/__/____ Age: ____

Patient Health Information

Patient Medical Care Information

Parent/Guardian Information

Complete the below information should the Patient be underage or need Guardian Consent:

Emergency Contact Information

Treatment Plan

The below schedule is the planned treatments devised for the Patient:

Enter value

Conditions

My Doctor has explained to me the following conditions exist in my case:

Enter value

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.

​

​[Patient.FirstName][Patient.LastName]​