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Selected excerpts from medicolegal forms
reports of co un cils and bureaus
Selected excerpts from medicolegal forms
Harvey Sarner * LL.B., Chicago
COUNCIL ON LEGISLATION
The Law Department of the American Medical Association has prepared a handy booklet entitled Medicolegal Forms W ith Legal Analysis1 in an en deavor to maintain professional respon sibility and minimize malpractice suits. Although this booklet was prepared with the physician in mind, many of the forms with slight modification are equally applicable to the dental profes sion. Oral surgeons and dentists who en gage in long term rehabilitation, perio dontic or orthodontic treatments may especially find these forms useful in their Form 2
daily practice, or for that “special pa tient” who is injury prone. The following are 15 of the 47 forms which appear in Medicolegal Forms. Some have been modified only slightly, merely changing “physician” to “dentist.” Others have been changed to a greater degree to reflect more adequately dental situations. These forms are offered only for information and guideposts and are no substitute for consultation with com petent legal counsel. For maximum legal effect the forms should be carefully ex plained when submitted for signature.
• Letter to confirm discharge by patient
Dear M r______________________________ : This will confirm our telephone conversation of today in which you discharged me from attend ing you as your dentist. In my opinion your condition requires continued dental treatment by a dentist. If you have not already done so, I suggest that you employ another dentist without delay. You may be assured that, at your request, I will furnish him with information regarding the diagnosis and treatment which you have received from me. Very truly yours, _ --------------- ------------------------------------------ , D.D.S.
144/878 • TH E J O U R N A L O F THE A M E R IC A N DENTAL A S S O C IA T IO N
Form 4 • L e tte r to p a tien t w ho fails to keep ap p o in tm en t Dear Mr..------ ---------------- -------- --------- — : On______________________________ 19______, you failed to keep your appointment at my office. In my opinion your condition requires continued dental treatment. If you so desire, you may telephone me for another appointment, but if you prefer to have another dentist attend you, I suggest that you arrange to do so without delay. You may be assured that, at your request, I am entirely willing to make available my knowledge of your case. I trust that you will understand that my purpose in writing this letter is out of concern for your health and well-being. Very truly yours, __________________________________________, D.D.S. Form 5 • L e tte r to p a tien t w ho fails to p erm it x-ray Dear M r_______________________________ : At the time th at you brought your son, William, to me for examination this afternoon, I in formed you that I was unable to determine without x-ray pictures whether further dental treatment is required. I strongly urge you to permit me or some other dentist of your choice to make this x-ray examination without further delay. Your neglect in not permitting a proper x-ray examination to be made may result in serious consequences. Very truly yours, __________________________________________, D.D.S. Form 7 • A u th o rizatio n fo r disclosure of inform atio n by p a tie n t’s dentist 1. I authorize D r_____________________________________ to disclose complete information to ____________________________________ concerning his dental findings and treatm ent of the undersigned from on or about _________________________________ 19_____ _ until date of the conclusion of such treatment. 2. Further, I authorize him to testify, without limitation, as to all of his dental findings and the treatm ent administered to the undersigned, in any legal action, suit, or proceedings to which I am, or may become a party; and I waive on behalf of myself and any persons who may have an interest in the matter, all provisions of law relating to the disclosure of confidential dental information. Signed ______________________________________ Place ____:_________________________________ Date ______________________________________ W itness_________________________________ Form 9 • A u th o rizatio n fo r ex am ination of dentist’s records To D r_________________________________: I authorize you to furnish a copy of the dental records o f __________________________________ , (State name of patient or “myself” ) covering the period from__________ =_____________ 19____ to________________________ 19____ or to allow those records to be inspected or copied b y _____________________________________ I release you from all legal responsibility or liability that may arise from this authorization. Signed ______________________________________ Date ______________________________________ Witness____________________________ • Form 1 1 * O rd e r fur tak ing of x-ray films
D a t e ______________________________________ Place ______________________________________ 1. I hereby order the taking of x-ray exposures and films of parts of the person of as follow s:_____________________________________ 2. I agree, in part consideration of D r____________________________ ’s undertaking to render professional service to the person named above, that all such x-ray exposures taken and films made by D r---------------------------------------------- - or by any other person at his request, whether or not paid for by the undersigned, shall become a part of D r______________________________ ’s professional records and shall be subject solely to his control and disposition.
REPORTS O F C O U N C IL S A N D BUREAUS . . . V O LU M E 63, DECEMBER 1961 • 145/879
3. In addition to the foregoing, I agree to pay charges in the amount of $_________________ for services rendered pursuant to this order. Signed______________________________________ Witness ____________________________________
Form 13 • Consent to taking and publication of photographs
Patient____________________________________ Place_____________________ Date_______________ In connection with the dental services which I am receiving from my dentist, D r____________ _ ______________________________, I consent that photographs may be taken of me or parts of my body, under the following conditions: 1. The photographs may be taken only with the consent of my dentist and under such conditions and at such times as may be approved by him. 2. The photographs shall be taken by my dentist or by a photographer approved by my dentist. 3. The photographs shall be used for dental records and if in the judgment of my dentist, dental research, education or science will be benefited by their use, such photographs and information relating to my case may be published and republished, either separately or in connection with each other, in professional journals, or used for any other purpose which he may deem proper in the interest of dental education, knowledge, or research; provided, however, that it is specifically understood that in any such publication or use I shall not be identified by name. 4. The afore-mentioned photographs may be modified or retouched in any way that my dentist, in his discretion, may consider desirable. Signed_______________________________________ (Patient) W itness________________________________
Form 16 • Consent to dental operation, anesthetics, and other dental services
A.M. Date------------------------------------Time____________ P.M. 1. I authorize the performance upon __________________________________________ of the (myself or name of patient) following dental operation _________________________________________________________________ (state nature and extent of operation) to be performed under the direction of D r_______________________________ 2. I consent to the performance of operations and procedures in addition to or different from those now contemplated, whether or not arising from presently unforeseen conditions, which the above-named doctor or his associates or assistants may consider necessary or advisable in the course of the operation. 3. I consent to the administration of such anesthetics as may be considered necessary or advisable by the dentist responsible for this service, with the exception of _ _ __________________ (state “none,” “spinal anesthesia,” etc.) 4. I consent to the photographing or televising of the operations or procedures to be per formed, including appropriate portions of my body, for dental, scientific or educational purposes, provided my identity is not revealed by the pictures or by descriptive texts accompanying them. 5. For the purpose of advancing dental education, I consent to the admittance of observers to the operating room. 6. I consent to the disposal by hospital authorities of any tissues, teeth or parts which may be removed. 7. The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me. No guaran tee or assurance has been given by anyone as to the results that may be obtained. (Cross out any paragraphs above which do not apply.) Signed______________________________________ (Patient or person authorized to consent for patient) W itness________________________________
146/880 • THE J O U R N A L OF TH E A M E R IC A N DENTAL A S S O C IA T IO N
Form 17 • Consent to oral surgery for cosmetic purposes
A.M. Date________________________Time____________ P.M. 1. I authorize D r________________________________ to perform oral surgery upon me for the purpose of attempting to improve my appearance with respect to the following condition:
2. The nature and effect of the operation to be performed, risks involved, as well as possible alternative methods of treatment, have been fully explained to me. 3. I also authorize the operating dental surgeon to perform any other procedures which he may deem desirable in attempting to improve the condition stated in paragraph 1 or any unhealthy or unforeseen condition that he may encounter during the operation. * 4. I consent to the administration of anesthetics to be applied by or under the direction of Dr______________________________ and to the use of such anesthetics as he may deem advisable. 5. I know that the practice of oral surgery is not an exact science and that therefore rep utable practitioners cannot guarantee results. No guarantee or assurance has been given by anyone as to the results that may be obtained. Signed ---------------------------------------------------------(Patient or person authorized to consent for patient) W itness________________________________
Form 25 • Consent to treatment
A.M. Date________________________Time____________-P.M. I have been fully informed by D r___________________________________ of the risks, possible alternative methods of treatment, and possible consequences involved in treatment by means of for the relief of _________________________________ _______________ Nevertheless, I authorize Dr.._______ _________________________ to administer such treatment to me. Signed _______________ ________________________ (Patient or person authorized to consent for patient) W itness________ ________________________ Form 2 6
• Acknowledgment of emergency treatment
Form 2 7
• Refusal to submit to treatment
A.M. Date________________________Time____________ P.M. I acknowledge that the dental care which (was) (is about to be) furnished t o _______________ ________________________________ by D r_________________________________ (was) (will be) (name of patient) limited solely to emergency treatment. I understand that it will be necessary to select another dentist and make immediate arrangements with him for a complete diagnosis and continua tion of treatment. (Cross out inappropriate words) Signed______________________________________ _ (Patient or person authorized to consent for patient) W itness-------------------------------------------------A.M. Date_______________________ Time____________ P.M. I have been advised by D r_________________________________ that it is necessary for me to undergo the following treatm ent:--------------------------------------------------------------------------------------(Describe operation or treatment) The effect and nature of this treatment have been explained to me. Although my failure to follow the advice I have received may seriously imperil my health.
REPORTS O F C O U N C IL S A N D BUREAUS . . . V O LU M E 63, DECEMBER 1961 • 147/881
I nevertheless refuse to submit to the recommended treatment. I assume the risks and conscquences involved and release the above-named dentist from any liability. Signed ______________________________________ Witness________________________________ _ Form
28 • Consent to experimental procedure or treatment
Form
29 • Authorization for treatment with drug under clinical investigation
A.M. Date_______________________ Time____________ P.M. I authorize the performance u p o n -----------------------------------------------------------of the following (myself or name of patient) procedure or treatm en t:__________________________________________________________________ (State nature of procedure or treatment.) The nature and purpose of the procedure or treatment, possible alternative methods of treatment, the risks involved, and the possibilities of complications have been explained to me. I fully understand that the procedure or treatment to be performed is experimental and unproven by dental experience, and that the consequences are unpredictable. Signed__ ____________________________________ (Patient or person authorized to consent for patient) Witness_________________________________ A.M. Date_______________________ Time____________ P.M. I authorize D r_________________________________ , to treat _________________________________ (name of patient)” with the drug presently identified as _____ ________________________________ for the following condition: ________________________________________________________________________________ (Describe symptoms of disease to be treated) It has been explained to me that the safety and usefulness of the drug in the treatment of patients for the above condition are now being investigated and that the manufacturer or distributor has supplied the drug for the purpose of providing further evidence of its safety and usefulness. I voluntarily consent to treatment with the drug and release Dr..___________ ________________________________ from liability for any results that may occur. Signed . (Patient or person authorized to consent for patient) W itness.
Form 33 • Consent to diagnostic procedure
A.M. Date------------------------------- ---- Time____________ P.M. I authorize D r------------------------------------------------------- , and such assistants as he may designate, to perform upon _______________________________________ the following diagnostic procedure: (myself or name of patient) The nature of this procedure, possible alternative methods of diagnosis and the risks of injury despite precautions have been explained to me. Signed_______________________________________ (Patient or person authorized to consent for patient) •A ssistant secretary, C o u n c il on L e g is la tio n . I. This b o o k le t is o b ta in a b le fro m th e A m e ric a n M e d ic a l A sso ciation , 535 N orth a t the cost o f $1.
D earborn Street, C h ic a g o
10,
Selected excerpts from medicolegal forms
Harvey Sarner * LL.B., Chicago
COUNCIL ON LEGISLATION
The Law Department of the American Medical Association has prepared a handy booklet entitled Medicolegal Forms W ith Legal Analysis1 in an en deavor to maintain professional respon sibility and minimize malpractice suits. Although this booklet was prepared with the physician in mind, many of the forms with slight modification are equally applicable to the dental profes sion. Oral surgeons and dentists who en gage in long term rehabilitation, perio dontic or orthodontic treatments may especially find these forms useful in their Form 2
daily practice, or for that “special pa tient” who is injury prone. The following are 15 of the 47 forms which appear in Medicolegal Forms. Some have been modified only slightly, merely changing “physician” to “dentist.” Others have been changed to a greater degree to reflect more adequately dental situations. These forms are offered only for information and guideposts and are no substitute for consultation with com petent legal counsel. For maximum legal effect the forms should be carefully ex plained when submitted for signature.
• Letter to confirm discharge by patient
Dear M r______________________________ : This will confirm our telephone conversation of today in which you discharged me from attend ing you as your dentist. In my opinion your condition requires continued dental treatment by a dentist. If you have not already done so, I suggest that you employ another dentist without delay. You may be assured that, at your request, I will furnish him with information regarding the diagnosis and treatment which you have received from me. Very truly yours, _ --------------- ------------------------------------------ , D.D.S.
144/878 • TH E J O U R N A L O F THE A M E R IC A N DENTAL A S S O C IA T IO N
Form 4 • L e tte r to p a tien t w ho fails to keep ap p o in tm en t Dear Mr..------ ---------------- -------- --------- — : On______________________________ 19______, you failed to keep your appointment at my office. In my opinion your condition requires continued dental treatment. If you so desire, you may telephone me for another appointment, but if you prefer to have another dentist attend you, I suggest that you arrange to do so without delay. You may be assured that, at your request, I am entirely willing to make available my knowledge of your case. I trust that you will understand that my purpose in writing this letter is out of concern for your health and well-being. Very truly yours, __________________________________________, D.D.S. Form 5 • L e tte r to p a tien t w ho fails to p erm it x-ray Dear M r_______________________________ : At the time th at you brought your son, William, to me for examination this afternoon, I in formed you that I was unable to determine without x-ray pictures whether further dental treatment is required. I strongly urge you to permit me or some other dentist of your choice to make this x-ray examination without further delay. Your neglect in not permitting a proper x-ray examination to be made may result in serious consequences. Very truly yours, __________________________________________, D.D.S. Form 7 • A u th o rizatio n fo r disclosure of inform atio n by p a tie n t’s dentist 1. I authorize D r_____________________________________ to disclose complete information to ____________________________________ concerning his dental findings and treatm ent of the undersigned from on or about _________________________________ 19_____ _ until date of the conclusion of such treatment. 2. Further, I authorize him to testify, without limitation, as to all of his dental findings and the treatm ent administered to the undersigned, in any legal action, suit, or proceedings to which I am, or may become a party; and I waive on behalf of myself and any persons who may have an interest in the matter, all provisions of law relating to the disclosure of confidential dental information. Signed ______________________________________ Place ____:_________________________________ Date ______________________________________ W itness_________________________________ Form 9 • A u th o rizatio n fo r ex am ination of dentist’s records To D r_________________________________: I authorize you to furnish a copy of the dental records o f __________________________________ , (State name of patient or “myself” ) covering the period from__________ =_____________ 19____ to________________________ 19____ or to allow those records to be inspected or copied b y _____________________________________ I release you from all legal responsibility or liability that may arise from this authorization. Signed ______________________________________ Date ______________________________________ Witness____________________________ • Form 1 1 * O rd e r fur tak ing of x-ray films
D a t e ______________________________________ Place ______________________________________ 1. I hereby order the taking of x-ray exposures and films of parts of the person of as follow s:_____________________________________ 2. I agree, in part consideration of D r____________________________ ’s undertaking to render professional service to the person named above, that all such x-ray exposures taken and films made by D r---------------------------------------------- - or by any other person at his request, whether or not paid for by the undersigned, shall become a part of D r______________________________ ’s professional records and shall be subject solely to his control and disposition.
REPORTS O F C O U N C IL S A N D BUREAUS . . . V O LU M E 63, DECEMBER 1961 • 145/879
3. In addition to the foregoing, I agree to pay charges in the amount of $_________________ for services rendered pursuant to this order. Signed______________________________________ Witness ____________________________________
Form 13 • Consent to taking and publication of photographs
Patient____________________________________ Place_____________________ Date_______________ In connection with the dental services which I am receiving from my dentist, D r____________ _ ______________________________, I consent that photographs may be taken of me or parts of my body, under the following conditions: 1. The photographs may be taken only with the consent of my dentist and under such conditions and at such times as may be approved by him. 2. The photographs shall be taken by my dentist or by a photographer approved by my dentist. 3. The photographs shall be used for dental records and if in the judgment of my dentist, dental research, education or science will be benefited by their use, such photographs and information relating to my case may be published and republished, either separately or in connection with each other, in professional journals, or used for any other purpose which he may deem proper in the interest of dental education, knowledge, or research; provided, however, that it is specifically understood that in any such publication or use I shall not be identified by name. 4. The afore-mentioned photographs may be modified or retouched in any way that my dentist, in his discretion, may consider desirable. Signed_______________________________________ (Patient) W itness________________________________
Form 16 • Consent to dental operation, anesthetics, and other dental services
A.M. Date------------------------------------Time____________ P.M. 1. I authorize the performance upon __________________________________________ of the (myself or name of patient) following dental operation _________________________________________________________________ (state nature and extent of operation) to be performed under the direction of D r_______________________________ 2. I consent to the performance of operations and procedures in addition to or different from those now contemplated, whether or not arising from presently unforeseen conditions, which the above-named doctor or his associates or assistants may consider necessary or advisable in the course of the operation. 3. I consent to the administration of such anesthetics as may be considered necessary or advisable by the dentist responsible for this service, with the exception of _ _ __________________ (state “none,” “spinal anesthesia,” etc.) 4. I consent to the photographing or televising of the operations or procedures to be per formed, including appropriate portions of my body, for dental, scientific or educational purposes, provided my identity is not revealed by the pictures or by descriptive texts accompanying them. 5. For the purpose of advancing dental education, I consent to the admittance of observers to the operating room. 6. I consent to the disposal by hospital authorities of any tissues, teeth or parts which may be removed. 7. The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me. No guaran tee or assurance has been given by anyone as to the results that may be obtained. (Cross out any paragraphs above which do not apply.) Signed______________________________________ (Patient or person authorized to consent for patient) W itness________________________________
146/880 • THE J O U R N A L OF TH E A M E R IC A N DENTAL A S S O C IA T IO N
Form 17 • Consent to oral surgery for cosmetic purposes
A.M. Date________________________Time____________ P.M. 1. I authorize D r________________________________ to perform oral surgery upon me for the purpose of attempting to improve my appearance with respect to the following condition:
2. The nature and effect of the operation to be performed, risks involved, as well as possible alternative methods of treatment, have been fully explained to me. 3. I also authorize the operating dental surgeon to perform any other procedures which he may deem desirable in attempting to improve the condition stated in paragraph 1 or any unhealthy or unforeseen condition that he may encounter during the operation. * 4. I consent to the administration of anesthetics to be applied by or under the direction of Dr______________________________ and to the use of such anesthetics as he may deem advisable. 5. I know that the practice of oral surgery is not an exact science and that therefore rep utable practitioners cannot guarantee results. No guarantee or assurance has been given by anyone as to the results that may be obtained. Signed ---------------------------------------------------------(Patient or person authorized to consent for patient) W itness________________________________
Form 25 • Consent to treatment
A.M. Date________________________Time____________-P.M. I have been fully informed by D r___________________________________ of the risks, possible alternative methods of treatment, and possible consequences involved in treatment by means of for the relief of _________________________________ _______________ Nevertheless, I authorize Dr.._______ _________________________ to administer such treatment to me. Signed _______________ ________________________ (Patient or person authorized to consent for patient) W itness________ ________________________ Form 2 6
• Acknowledgment of emergency treatment
Form 2 7
• Refusal to submit to treatment
A.M. Date________________________Time____________ P.M. I acknowledge that the dental care which (was) (is about to be) furnished t o _______________ ________________________________ by D r_________________________________ (was) (will be) (name of patient) limited solely to emergency treatment. I understand that it will be necessary to select another dentist and make immediate arrangements with him for a complete diagnosis and continua tion of treatment. (Cross out inappropriate words) Signed______________________________________ _ (Patient or person authorized to consent for patient) W itness-------------------------------------------------A.M. Date_______________________ Time____________ P.M. I have been advised by D r_________________________________ that it is necessary for me to undergo the following treatm ent:--------------------------------------------------------------------------------------(Describe operation or treatment) The effect and nature of this treatment have been explained to me. Although my failure to follow the advice I have received may seriously imperil my health.
REPORTS O F C O U N C IL S A N D BUREAUS . . . V O LU M E 63, DECEMBER 1961 • 147/881
I nevertheless refuse to submit to the recommended treatment. I assume the risks and conscquences involved and release the above-named dentist from any liability. Signed ______________________________________ Witness________________________________ _ Form
28 • Consent to experimental procedure or treatment
Form
29 • Authorization for treatment with drug under clinical investigation
A.M. Date_______________________ Time____________ P.M. I authorize the performance u p o n -----------------------------------------------------------of the following (myself or name of patient) procedure or treatm en t:__________________________________________________________________ (State nature of procedure or treatment.) The nature and purpose of the procedure or treatment, possible alternative methods of treatment, the risks involved, and the possibilities of complications have been explained to me. I fully understand that the procedure or treatment to be performed is experimental and unproven by dental experience, and that the consequences are unpredictable. Signed__ ____________________________________ (Patient or person authorized to consent for patient) Witness_________________________________ A.M. Date_______________________ Time____________ P.M. I authorize D r_________________________________ , to treat _________________________________ (name of patient)” with the drug presently identified as _____ ________________________________ for the following condition: ________________________________________________________________________________ (Describe symptoms of disease to be treated) It has been explained to me that the safety and usefulness of the drug in the treatment of patients for the above condition are now being investigated and that the manufacturer or distributor has supplied the drug for the purpose of providing further evidence of its safety and usefulness. I voluntarily consent to treatment with the drug and release Dr..___________ ________________________________ from liability for any results that may occur. Signed . (Patient or person authorized to consent for patient) W itness.
Form 33 • Consent to diagnostic procedure
A.M. Date------------------------------- ---- Time____________ P.M. I authorize D r------------------------------------------------------- , and such assistants as he may designate, to perform upon _______________________________________ the following diagnostic procedure: (myself or name of patient) The nature of this procedure, possible alternative methods of diagnosis and the risks of injury despite precautions have been explained to me. Signed_______________________________________ (Patient or person authorized to consent for patient) •A ssistant secretary, C o u n c il on L e g is la tio n . I. This b o o k le t is o b ta in a b le fro m th e A m e ric a n M e d ic a l A sso ciation , 535 N orth a t the cost o f $1.
D earborn Street, C h ic a g o
10,