Free Informed Financial Consent Form Template PDF | Coflow

Written by Coflow | Nov 12, 2026, 2:25:47 AM

Free template

Digital informed financial consent form

Send your informed financial consent form digitally to your patients. With Coflow, they read the fees, tick each statement and sign on their phone or computer before their surgery, with no app and no login.

Add each patient’s procedure, surgeon and fee quote before you send it. The signed form is waiting for you on the task, and responses write back to your practice management system.

Send it digitally See template

Summary of fees from our rooms

Total fee

Est. Medicare + fund rebate

Est. out of pocket

Informed Financial Consent

Step 4 of 5

Please tick each statement to confirm

I have received a written quote for my surgeon’s and assistant’s fees.*

I understand the estimated out-of-pocket amount I will need to pay, and when it is due.*

Signed

Sent by SMS or email
Read and ticked
Signed
Filed to your PMS

Signed before surgery No paper chasing

Stored in Australia

No patient app or login

Collect e-signatures

Writes back to your PMS

Try the digital informed financial consent form

Coflow forms are flexible and mobile responsive. Patients fill it in on any phone or computer, with no app and no login.

informed-financial-consent.pdfPage 1 of 1Download

Informed Financial Consent

Your surgery: the costs involved and what you may pay yourself

Practice letterhead

Before your surgery, we want you to understand the costs involved and what you may need to pay yourself. Please read this form together with your fee quote, ask us about anything that is unclear, and sign below.

Your details

Patient

Procedure

Surgeon

Hospital

Proposed date

Fee quote

Summary of fees from our rooms

Total fee

Est. Medicare + fund rebate

Est. out of pocket

Please tick each statement to confirm

I have received a written quote for my surgeon’s and assistant’s fees. *

I understand the estimated out-of-pocket amount I will need to pay, and when it is due. *

I understand the anaesthetist and hospital will bill me separately, and that other services (such as pathology, radiology or prostheses) may also be billed separately. *

I understand that Medicare and health fund rebates are estimates, and that I should confirm my cover with my health fund. *

I understand that fees may change if my procedure changes, and that the practice will discuss any changes with me. *

I have had the opportunity to ask questions about the fees, and my questions have been answered. *

Consent

Patient name *

Date *

Signature *

Informed Financial Consent. Read together with your written fee quote.Page 1 of 1

9:41

Informed Financial Consent

Preview only, with a made-up practice, patient and fees. Nothing you tick, type or sign is saved or sent.

Filled by your practice

Step 1 of 5

Introduction

Harbourside Orthopaedics — Suite 4, 12 Wharf Road, Sydney NSW 2000 | (02) 5550 1234 | rooms@harbourside.example

Step 2 of 5

Your details

Patient: Sam Citizen Procedure: Right knee arthroscopy Surgeon: Dr Alex Harbour Hospital: Harbourside Private Hospital Proposed date: Tue 9 Feb 2027 Fee quote: Q-1042, issued 12 Jan 2027

Step 3 of 5

Summary of fees from our rooms

Total fee $4,200 | Est. Medicare + fund rebate $2,650 | Est. out of pocket $1,550

Step 4 of 5

Please tick each statement to confirm

I have received a written quote for my surgeon’s and assistant’s fees.*This field is required.

I understand the estimated out-of-pocket amount I will need to pay, and when it is due.*This field is required.

I understand the anaesthetist and hospital will bill me separately, and that other services (such as pathology, radiology or prostheses) may also be billed separately.*This field is required.

I understand that Medicare and health fund rebates are estimates, and that I should confirm my cover with my health fund.*This field is required.

I understand that fees may change if my procedure changes, and that the practice will discuss any changes with me.*This field is required.

I have had the opportunity to ask questions about the fees, and my questions have been answered.*This field is required.

Step 5 of 5

Consent

Patient name*This field is required.

Date*

DayMonthYear

This field is required.

Signature*

Sign here

This field is required.

Form completed

When a patient signs it for real, the signed form is filed to their record in your practice management system.

Send it digitally

Patients read, tick and sign on their phone or computer before their surgery, with no app or login. Coflow sends a reminder if they don’t finish, and files the signed form into your PMS.

Collect e-signatures
Automatic reminders
Writes back to your PMS

Book a demo

We’ll show you the form in Coflow and set it up with you.

PDF

Start with the free PDF

We’ll email you the printable informed financial consent form, plus a few ideas for moving your forms online when you’re ready.

Download the free PDF

On its way. Check your inbox, or download it now.

Download the PDF

Writes back to

and more: Nookal and Cliniko

Learn more

Ready to send your forms digitally?

Book a demo and we’ll show you how Coflow sends forms by SMS or email, collects e-signatures and files answers into your practice management software.

Book a demo

View full post