ortho release form

Orthopedic Treatment Waiver and Liability Release

Instructions for Use

• Complete all bracketed fields accurately using the legal names of the parties involved.
• Ensure the patient or authorized legal guardian initials each numbered clause to confirm understanding of the risks.
• Retain a signed copy for your medical records and provide a duplicate to the patient for their personal files.

Parties and Definitions

This Agreement is entered into on this [] day of [], 20[__], by and between:

Provider: [Name of Orthopedic Practice/Clinic], located at [Office Address] ("Provider").

Patient: [Full Legal Name of Patient], residing at [Patient Address] ("Patient").

Operative Terms

1. Nature of Treatment: Patient acknowledges that they are seeking orthopedic care, which may include physical examinations, diagnostic imaging, surgical procedures, injections, or physical therapy. Patient understands that all medical treatments involve inherent risks.

2. Assumption of Risk: Patient acknowledges that orthopedic procedures involve potential complications, including but not limited to infection, nerve damage, blood clots, failure of hardware, allergic reactions to anesthesia or medication, and incomplete recovery. Patient voluntarily assumes all such risks.

3. Informed Consent: Patient confirms they have had the opportunity to ask questions regarding the proposed treatment plan, alternative options, and the potential consequences of declining treatment. All questions have been answered to the Patient’s satisfaction.

4. Release of Liability: To the fullest extent permitted by law, Patient hereby releases, waives, and discharges Provider and its employees, agents, and affiliates from any and all claims, demands, or causes of action arising out of or related to any loss, damage, or injury that may be sustained by the Patient while undergoing treatment, except in cases of gross negligence or willful misconduct.

5. Financial Responsibility: Patient agrees to be responsible for all costs associated with the treatment provided, regardless of insurance coverage, and acknowledges that they are responsible for verifying their own insurance benefits.

6. Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the state of [State Name].

Signature and Acknowledgment

By signing below, I certify that I have read this document in its entirety, I understand its contents, and I am signing it voluntarily.

Patient/Guardian Signature: __________

Printed Name: [__________]

Title/Relationship: [Self / Parent / Legal Guardian]

Date: [__________]

Legal Disclaimer: This document is a general framework and does not constitute formal legal advice. Laws regarding medical liability and informed consent vary significantly by jurisdiction; please consult with qualified legal counsel to ensure this document meets all local, state, and federal regulatory requirements.