PRIVATE BLANK CONSENT-QUESTION RECORD
Proposed examination/investigation/treatment:
Explanation received and its source/date:
Material risks/expected outcomes explained by the practitioner:
Question still needing an answer:
Communication or interpreting arrangement to clarify:
Time/questions needed before the decision:
Required services and fees discussed:
Any separate teaching/research purpose:
Any separate disclosure recipient/purpose:
How the practice records the conversation:
This worksheet does not assess risk, establish consent or recommend care. Keep it privately.