Streamline orthopedic surgical consent with a professional form covering patient info, procedure details, risks, and procedure authorization in one place.
Orthopedic Surgery Informed Consent & Procedure Authorization Form
Patient Full Name
· · ·
Date of Birth
· · ·
Patient Phone Number
· · ·
Submit
The Orthopedic Surgery Informed Consent & Procedure Authorization Form is a comprehensive digital form designed to help orthopedic practices, hospitals, and surgical centers obtain legally documented patient consent before any surgical procedure. It captures essential patient information, surgeon details, planned procedure specifics, surgical site and laterality confirmation, and a thorough risk acknowledgment section.
This template is ideal for orthopedic surgeons, surgical coordinators, and healthcare administrators who need a standardized, professional consent process. It ensures patients are fully informed about their diagnosis, alternative treatments discussed, and all potential risks associated with their orthopedic procedure — reducing liability and improving patient trust.
By digitizing the informed consent process, your practice can eliminate paper-based inefficiencies, collect signatures electronically, and securely store consent records. Whether you're performing joint replacements, fracture repairs, or soft tissue surgeries, this template ensures compliance, clarity, and a smooth pre-operative workflow.
4Pages
31Questions
~10minTo complete
FreeNo credit card needed
Field types
Short Text ×7
singlecheckbox ×7
Date ×3
Phone ×2
Long Text ×2
Signature ×2
Full Name
Email
Address
Dropdown
Single Choice
Multiple Choice
Yes / No
termsandconditions
Questions in this template
Free template
The exact questions included — customize any of them to fit your needs.
Page 1Patient Information8 questions
Patient Information
1
Patient Full Name
*Full Name
2
Date of Birth
*Date
3
Patient Phone Number
*Phone
4
Patient Email Address
Email
5
Patient Home Address
*Address
6
Emergency Contact Name
*Short Text
7
Emergency Contact Phone Number
*Phone
8
Relationship to Patient
*Short Text
Page 2Procedure Details7 questions
Surgical Procedure Information
1
Name of Orthopedic Surgeon / Physician
*Short Text
2
Planned Surgical Procedure
*Short Text
3
Surgical Site / Body Part
*Dropdown
4
Laterality Confirmation
*Single Choice
5
Scheduled Date of Surgery
*Date
6
Diagnosis / Reason for Surgery
*Long Text
Alternative Treatments Discussed
7
Alternatives to surgery that have been discussed with me include:
*Multiple Choice
Page 3Risks, Acknowledgments & Consent9 questions
Risks & Acknowledgments
All surgical procedures carry inherent risks. By signing this form, you acknowledge that your surgeon has explained the following potential risks and complications associated with your orthopedic procedure. Please read each statement carefully.
1
I understand the nature of the proposed surgical procedure and its expected benefits.
*singlecheckbox
2
I have been informed of the material risks, including but not limited to: infection, blood loss, blood clots, nerve or blood vessel damage, implant failure, chronic pain, limited range of motion, need for additional surgery, adverse reaction to anesthesia, and in rare cases, disability or death.
*singlecheckbox
3
I understand that no guarantees have been made regarding the outcome of the surgery.
*singlecheckbox
4
I consent to the administration of anesthesia as deemed appropriate by the anesthesia care team.
*singlecheckbox
5
I authorize the surgical team to perform any additional procedures that may be deemed medically necessary during the operation.
*singlecheckbox
6
I consent to the use of blood products or transfusions if medically required.
*singlecheckbox
7
I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.
*singlecheckbox
8
Do you have any known allergies to medications, latex, or anesthesia?
*Yes / No
9
If yes, please list all known allergies and reactions
Long Text
Page 4Authorization & Signatures7 questions
Patient Authorization
By signing below, I confirm that I have read and understood all information provided, that I have been given the opportunity to discuss the procedure and its risks with my physician, and that I voluntarily consent to the orthopedic surgical procedure described in this form.
1
I have read, understood, and agree to the terms outlined in this Informed Consent & Procedure Authorization Form.
*termsandconditions
5
Relationship to Patient (if signed by representative)
Short Text
6
Witness Signature
*Signature
7
Witness Printed Name
*Short Text
How to use this template
Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.
Ready-to-use structure — pre-configured fields out of the box
Applied "Matcha" theme — fonts, colors, and layout already set
Mobile-responsive — works on every device without extra configuration
Fully editable with drag-and-drop — change anything in seconds
Free to use on any plan, no credit card required
Use this template
Free to use. Open in the editor, customize, and publish in minutes.
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