Surgery Consent template

A surgical consent form that records the consent conversation rather than replacing it: procedure and scheduled date, a display-only summary of what the patient is agreeing to, five acknowledgments confirmed individually, a branch for outstanding questions, a post-op contact, and an e-signature. The welcome text says outright that the surgeon confirms consent in person on the day.

Use this template Start free — no card

12 questions · works on the free plan (500 responses/month) · fully customizable

1 built-in logic rule
E-signature question

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Patient's full legal nameShort text

02Date of birthDate

03Procedure you are scheduled forShort text

04Scheduled date of the procedureDate

05What you are consenting toStatement

06Please confirm each of the followingCheckboxes

07Do you still have questions for the surgical team?Multiple choice

08What would you like to ask?Long text

09Who should we contact after your procedure?Short text

10Sign to record your consentE-signature

When to use this template

A surgical center capturing consent between the pre-op consultation and the procedure date, so paperwork is not being signed in a gown
A day-surgery clinic that wants outstanding patient questions surfaced in writing early enough to answer them by phone
A specialist practice replacing a scanned PDF consent that patients returned unsigned or unreadable
A practice manager who needs each consent stored with a timestamp alongside the rest of the pre-op file

Tips to get more from it

The "What you are consenting to" statement is display-only placeholder text describing a generic procedure. Replace it with your own procedure-specific disclosures before publishing — it is the one field on this form that must not ship as written
The five acknowledgments are a single required multi-select, so the patient confirms each point individually instead of ticking one blanket agreement
The questions branch is doing real clinical work: answering "Yes" opens a free-text box, and those answers are a call list for the pre-op nurse
The e-signature is a Pro question type. You can build and preview the form free, but publishing a form containing a signature requires Pro at $14.99/mo

Questions people ask

Is a signature captured on this form legally valid consent?

We make no claim about legal validity. Zunoform records the drawn signature with the response and the date and time it was submitted. Whether that meets your jurisdiction's requirements for surgical consent is a question for your legal or compliance advisor, and the form's own copy says the surgeon confirms consent in person regardless.

Does this replace the consent conversation with the surgeon?

No, and the welcome screen says so. It documents a conversation that has already happened and flags anything the patient still wants to ask before the day.

What plan do I need to publish this form?

Pro at $14.99/mo, because of the e-signature field. Everything else in the template publishes on the free plan, so replacing the signature with a typed-name confirmation keeps it free.

Can I use this for a HIPAA-covered practice?

Zunoform does not offer a HIPAA Business Associate Agreement, and we would rather say that plainly than have you discover it in a compliance review. If you handle protected health information under HIPAA, use a provider that will sign a BAA.