Clinic template
A Cliniko informed consent form template for allied health clinics
This is the general treatment consent every patient signs once, covering how findings and treatment options are explained, material risks, alternatives to treatment, and the right to withdraw consent at any time. It is built as a Cliniko patient form, and the dry needling and other technique specific consents in this cluster add to it rather than repeating it.
Last checked 25 Sep 2026 against the sources listed at the end of this page.
Free template ยท Cliniko
Patient form: general consent: allied health (general)
The template: 12 fields
| Section | Field | Type | Notes |
|---|---|---|---|
| What this covers | Explanation of scope | Text | Cliniko type: Paragraph text (shown as a description, not a question). State plainly that this consent covers assessment and standard treatment techniques used at the clinic, and that specific procedures such as dry needling have their own separate consent form. |
| Assessment and treatment | I understand my practitioner will assess my condition and explain their findings | Checkboxes | Options: I understand and agree. |
| Assessment and treatment | I understand treatment options, expected benefits and material risks will be explained before treatment begins | Checkboxes | Options: I understand and agree. |
| Assessment and treatment | Common risks explained | Checkboxes | Options: Temporary soreness or discomfort / Bruising / Aggravation of symptoms / Rarely, more serious injury. Tick the ones relevant to the clinic's usual techniques. |
| Alternatives and questions | I understand alternatives to the proposed treatment, including no treatment, have been or can be discussed | Checkboxes | Options: I understand and agree. |
| Alternatives and questions | I have had the chance to ask questions and they have been answered to my satisfaction | Checkboxes | Options: I understand and agree. |
| Costs | I understand the clinic's fees and any rebate or funding arrangement have been explained | Checkboxes | Options: I understand and agree. |
| Withdrawal of consent | I understand I may withdraw my consent to any part of treatment at any time, without needing to give a reason | Checkboxes | Options: I understand and agree. |
| Withdrawal of consent | I understand this consent applies to standard techniques only, and specific procedures such as dry needling will be discussed and consented to separately | Checkboxes | Options: I understand and agree. |
| Sign off | Patient name | Text | Connected question, matches the patient record. |
| Sign off | Date | Text | Use Cliniko's Date question type here if a picker is wanted. |
| Sign off | Signature | Text | Captured however your Cliniko account's patient form signature option is configured. |
Build it in Cliniko
- Go to Settings > Patient form templates as an Administrator, click Add template and name it General treatment consent.
- Write the What this covers section as plain description text at the top of the form, stating clearly that this consent covers standard assessment and treatment and that specific procedures have their own separate form, so patients are not left assuming one signature covers everything.
- Add each consent statement above as its own Checkboxes question with a single option, I understand and agree, rather than one long paragraph the patient has to read and remember in full. Splitting the statements out means a report of the submitted form shows exactly which points were agreed to.
- Include the form as a placeholder in the same appointment confirmation email as the intake form, or send it as a one-off to existing patients who have not yet completed it.
- Set the template to update automatically each time you materially change the clinic's standard techniques or fee structure, and ask returning patients to resign it if enough has changed since they last signed.
- Test the form as a patient, submit it, and confirm the completed consent appears against the correct patient record and prints clearly if it needs to be produced for a complaint or audit.
AHPRA: The shared Code of conduct for registered health practitioners expects informed consent for assessment and treatment, covering the nature of the proposed treatment, its material risks, alternatives, and the patient's right to withdraw consent at any time. This template gives each of those elements its own line so the record shows what was actually agreed to.
One general consent, several specific ones
A clinic that treats every patient the same way for consent purposes usually ends up with one of two problems: a form so broad it says nothing about the risks of a specific technique, or a form so specific to one procedure that it never gets used for anything else. This template is the general layer: what every patient agrees to before any assessment or standard treatment happens. Dry needling and other higher risk or more specific procedures in this cluster get their own separate form that a patient signs in addition to this one, not instead of it, which the general consent says explicitly in its opening section.
Why each statement is its own checkbox
A single block of consent text that a patient ticks once is hard to defend later if a specific point is disputed, because there is no way to show which part of a long paragraph the patient actually read and understood. Splitting findings, risks, alternatives, cost and withdrawal into separate statements, each with its own checkbox, means a submitted form shows exactly which elements of informed consent were presented and agreed to, which matches how the Code of conduct describes informed consent as made up of several distinct elements rather than one blanket agreement.
Withdrawal gets equal weight to giving consent
Consent forms often emphasise what the patient is agreeing to and treat the right to withdraw as an afterthought buried in small print. This template gives withdrawal its own statement, worded plainly, because a patient who does not realise they can stop a technique partway through has not really given informed consent to it in the first place.
Sources
- Cliniko patient form templates are created under Settings > Patient form templates using sections and individual questions, can include connected questions tied to the patient's own record, and can be sent via appointment confirmation emails or as a one-off to an individual patient. Cliniko Help, checked 25 Sep 2026.
- Cliniko supports sending a patient form to an individual patient as a one-off, separate from the automated confirmation and reminder email flow, for patients who need to complete or redo a form outside the standard booking process. Cliniko Help, checked 25 Sep 2026.
- The shared Code of conduct for registered health practitioners, applied by each National Board including the Physiotherapy Board of Australia, describes informed consent as covering the proposed treatment, expected benefits, material risks, alternatives (including no treatment), and the patient's right to withdraw consent at any time. Physiotherapy Board of Australia, checked 25 Sep 2026.