A written record that the patient agreed to assessment and treatment after you explained what it involves, the material risks, and the alternatives. It is for physiotherapists, and works with light editing for osteopaths, chiropractors and sports therapists.
The signature is not the consent. Consent is the conversation; this form is evidence that it happened and what it covered. It also keeps treatment consent apart from data protection, which UK practices often blur together.
The UK standards it rests on
HCPC Standards of conduct, performance and ethics
Registrants must get valid consent before providing care and respect a person's right to refuse or withdraw it.
Chartered Society of Physiotherapy (CSP) guidance on consent
The professional body's guidance on what informed consent means in physiotherapy practice, including when written consent is advisable.
Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015)
Set the UK test for informed consent: patients must be told about material risks and reasonable alternatives, judged by what matters to that patient.
Mental Capacity Act 2005 (England and Wales) and Gillick competence
Govern capacity to consent for adults and for under-16s. Scotland and Northern Ireland have their own capacity law.
UK GDPR Article 9 and the Data Protection Act 2018, Schedule 1
Health data is special category data. A practice usually processes it under the health care condition rather than consent, which is why this form does not ask the patient to consent to data processing.
Must include
Patient name, date of birth and the treating clinician
Ties the record to one patient and one named professional who took the consent.
What the proposed assessment and treatment involve
Consent only covers what was explained. Name the techniques, especially manual therapy, manipulation, acupuncture or dry needling, and anything involving undressing.
Material risks and common side effects
The Montgomery test turns on whether a reasonable person in the patient's position would want to know. Post-treatment soreness is the minimum; add technique-specific risks.
Reasonable alternatives, including doing nothing
Montgomery requires alternatives to be discussed, not just the option you recommend.
The right to ask questions, stop, or withdraw consent at any time
Consent is ongoing. A patient who agreed in session one can decline a technique in session four.
Signature and date of patient and clinician
Evidence of when the discussion took place. Re-take consent when the treatment plan changes materially.
Optional
Chaperone offer and response
Strongly advisable for any examination involving undressing or intimate areas. Record whether it was offered and accepted.
Parent or guardian section
Needed for under-16s who are not Gillick competent. Use a separate parental consent form if most of your caseload is children.
Interpreter used
Shows the patient understood the explanation when English is not their first language.
Short privacy notice reference
UK GDPR Article 13 requires privacy information at the point you collect data. Linking to your privacy notice here is convenient, but keep it informational.
The template
Replace anything in [square brackets]. Print it, save it as a PDF from the print dialog, or copy the text into your own document.
We keep your clinical records to provide your care and to meet our legal and professional duties. How we use and store your information is set out in our privacy notice: [Link to privacy notice].
Use it in Atlacare
On paid plans, build this as a form in Atlacare's form builder, using statement, yes/no and signature fields. The form library already includes a GDPR consent form and a parent or guardian consent form for under-18s that you can add alongside it. Completed forms are saved to the patient record, and the form can be sent to the patient by secure link before their first appointment.
Atlacare