A form to support the conversation
This two-page template includes space for the tool, capture method, data recipients, and retention details. It explains the purpose, privacy risks, alternatives, and the choice to consent or decline. Your clinician reviews and edits the draft before finalizing the record.
Download the consent template (PDF)
Before using the form
Complete the practice and tool details before discussing it with a patient. Adapt it to the actual vendor practices, applicable law, and professional requirements. The form does not replace the privacy and security review needed before client information enters a tool.
The PDF has fillable information fields and checkboxes, plus space for handwritten signatures. Select one consent choice. Discuss both pages together, and keep them together as one form. Complete patient information through your practice’s approved process; do not send completed forms through this website.
Related guides
Read AI and Clinical Documentation and Can I Put Client Information Into an AI Tool?. Use the data-handling worksheet to review the information path before use.