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Use our free medical waiver of liability form to create a legal document that releases the medical professional or organization from liability for any injuries, damages, or adverse medical effects that may occur during the treatment. Our form template ensures transparency and risk acknowledgment for all parties involved.

Medical Liability Waiver Form

Prepared for:

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

Image 1

Prepared by:

​[Sender.FirstName][Sender.LastName][Sender.Company]​

​[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.

You can customize this form for underage children and of age persons. We also recommend filling in the company details, like the name and treatment plan. This section ensures the correct information is on the form for the Patient to know.

Patient Information

This medical liability waiver form sample suggests separate sections for the Patient to complete. This data is critical information when receiving the Patient’s consent.

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

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

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

Patient Health Information

Health Conditions (e.g., Asthma, Diabetes, etc.):

Allergies (e.g., Medications, Food):

Prescribed Medication:

Date of Last Tetanus Shot/Booster:

Patient Medical Care Information

Physician/Pediatrician:

Phone Number:

Dentist/Orthodontist:

Phone Number:

Preferred Medical Facility:

​

Insurance Company:

​

Policy/Group Number:

Policy Holder:

Parent/Guardian Information

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

Parent/Guardian Name: [Guardian1.FirstName][Guardian1.LastName]​

Address: [Guardian1.StreetAddress][Guardian1.City][Guardian1.State][Guardian1.PostalCode]

Phone Number (H): [Guardian1.Phone]​

Phone Number (C):

Phone Number (W):

Emergency Contact Information

Emergency Contact Name:

Parent/Guardian Name:

Phone Number (H):

Phone Number (C):

Phone Number (W):

Email:

Treatment Plan

This section is optional for form liability waiver form, wherever you may include it for getting medical consent. You may add the full scope of the treatment plan or outline the treatments you’ll start with.

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

This box requires adding any of the Treatment’s complications, risks, or benefits. While you’ll have a section covering you generally, it’s better to add information on what you know might happen. This knowledge is a significant part of the Patient giving proper consent.

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.

Our form template is customizable, and if you want to print it, you can download it as a PDF. You can also send it to the Patient for them to fill out and add their signature.

​

Signature
MM / DD / YYYY

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

​

Signature
MM / DD / YYYY

​

Signature
MM / DD / YYYY

​[Guardian1.FirstName][Guardian1.LastName]​

​[Guardian2.FirstName][Guardian2.LastName]​

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FAQ: Medical Liability Waiver Form

  • Medical Liability Waiver Form is a legal document that protects both the medical professional or organization and the participant by clearly outlining the risks involved in the medical activity and obtaining the participant’s informed consent.

  • Medical professionals, healthcare providers, clinics, hospitals, and any organization or individual organizing medical activities, procedures, or events should use a medical liability waiver form. This includes fitness centers, sports clubs, wellness retreats, clinical trials, and any other setting where participants engage in medical-related activities or procedures.

  • In this form, you must include the Patient’s name and contact details and the medical institution’s name. The Patient’s current and past medical state is also required. It also needs a description of their Treatment, possible risks, and any terms of the agreement. Add the date and time the Patient signs the document and their signature or their Guardian’s.

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Medical Liability Waiver Form

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Obtain informed consent, acknowledge potential risks, and minimize liability exposure with our customizable Medical Liability Waiver Form template.

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