Minor surgery consent form: what GP practices need to capture

Valid consent is the backbone of GP minor surgery. Beyond the legal requirement, a strong consent process reassures patients, protects clinicians, and gives Care Quality Commission (CQC) inspectors confidence that your service is safe and well-led. This companion to our Minor surgery checklist per patient article summarises what to capture on a consent form, how to handle the conversation, and the practical evidence you should file every time.

Quick win: Build your consent template so it works in both printed and electronic form. That way you can email pre-reading, print copies on the day, and file notes directly to the patient record without double entry.

Core principles for valid consent

• Freely given: Patients must feel able to decline or defer without pressure. Offer time to think and a route to change their mind later.

• Informed: Explain benefits, material risks, and reasonable alternatives (including doing nothing), following the Montgomery standard.

• Specific: Consent relates to the named procedure, the clinician performing it, and any associated specimen handling or photography.

• Documented: The conversation matters as much as the signature. Record who spoke to the patient, the information shared, and any questions answered.

Essential elements to include on the form

• Patient and clinician details: Full patient identifiers, named clinician, assistant or chaperone if present, and space for contact numbers.

• Procedure description: Plain English summary of what will happen, why it’s needed, and expected outcomes (e.g., “Excision of epidermoid cyst on left shoulder”).

• Benefits and risks: List the common and serious risks relevant to primary care minor surgery (bleeding, infection, scarring, nerve damage, recurrence, anaesthetic reactions). Use bullet points so patients can scan easily.

• Alternatives and option to decline: Note conservative management, referral to secondary care, or watchful waiting if appropriate.

• Aftercare commitments: Outline dressing changes, activity restrictions, and who to contact if red flag symptoms appear. Link to your post-procedure leaflet.

• Specimens and photos: Gain consent for histology submission, photography, or digital storage where used. Provide opt-out tick boxes.

• Medication and safeguarding prompts: Record anticoagulation advice, allergy confirmation, safeguarding considerations, and interpreter use.

• Patient statements: Include tick boxes confirming they have had the chance to ask questions, understand they can withdraw consent, and accept the plan.

• Signatures and dates: Patient, clinician, and witness/chaperone signatures with printed names. Add a space for the interpreter if involved.

Timing and workflow tips

1. Send information ahead: Provide an accessible leaflet covering the procedure, risks, and aftercare when the appointment is booked. This gives patients time to reflect.

2. Record same-day discussion: On the day, recap the key points verbally, address new questions, and document any changes from the plan.

3. Check capacity: Confirm the patient understands the information and can weigh up decisions. If you have any doubt - or capacity fluctuates - pause the procedure (unless urgent), document the assessment, and follow your Mental Capacity Act best-interest process before proceeding.

4. Offer a chaperone: Even for non-intimate procedures, note the offer and the patient’s choice.

5. Allow a cooling-off option: Unless the procedure is urgent, reassure patients they can reschedule. This supports shared decision-making and reduces complaints.

6. Link with the clinical record: Upload the signed consent form and copy key points into the consultation notes, including SNOMED or Read codes mandated by the Directed Enhanced Service (DES).

How long to keep consent records

• Follow NHS Records Management Code of Practice 2024 retention periods (usually 8 years for adults, until the patient’s 25th birthday for children—or 26th if treated at 17—and longer for maternity or trauma-related records).

• Store digital copies in a secure document management area within your clinical system. For paper forms, file them in the scanned correspondence workflow on the same day.

• Log any withdrawn or amended consent so the latest version is easy to find during audits.

Communicating risks without alarm

• Frame statistics meaningfully (“Around 1 in 20 people experience bruising; serious bleeding is rare, but we discuss it so you know what to look for”).

• Tailor risk emphasis to the patient’s circumstances (e.g., diabetes, anticoagulation, smoking).

• Use visual aids or diagrams for complex procedures; these can be referenced in the consent note.

• Encourage questions such as “What matters most to you about this procedure?” to surface hidden concerns.

Linking consent to safety checklists

• Tie consent review into the “before incision” pause from your minor surgery checklist. Confirm the patient still agrees, understands aftercare, and knows how specimens will be handled.

• For line-of-variation procedures (e.g., biopsies that could escalate to excisions), document the potential change in scope and the patient’s acceptance in advance.

• If a procedure is postponed, record that consent will be re-confirmed on the new date and flag any follow-up actions.

Template snippet you can adapt

Consent summary template Procedure: ________________________________ Benefits discussed: _______________________ Risks discussed (tick): bleeding ☐ infection ☐ scarring ☐ recurrence ☐ nerve injury ☐ other: __________ Alternatives discussed: referral ☐ conservative management ☐ watchful waiting ☐ other: __________ Specimen to histology: yes ☐ no ☐ Photography: consented ☐ declined ☐ Anaesthetic batch/expiry recorded in notes: yes ☐ Post-procedure contact details provided: yes ☐ Patient signature __________________ Date ______ Clinician signature ________________ Date ______ Witness/chaperone ________________ Role ______ Interpreter _______________________ Role ______

Feel free to embed this section in your patient letters or electronic questionnaire so it feeds directly into the clinical record.

Quality assurance ideas

• Spot check monthly: Randomly audit a handful of minor surgery cases to confirm the consent form is complete and the consultation notes match.

• Use patient feedback: After the procedure, ask whether the consent conversation felt clear and respectful. Incorporate insights into team briefings.

• Keep versions in sync: Whenever you update risks or aftercare instructions, refresh the consent form, patient leaflet, and clinical templates together.

• Train new staff: Include consent walkthroughs in induction for GPs, advanced practitioners, and healthcare assistants supporting the clinic.

Disclaimer: This article is for informational purposes only and reflects understanding as of the publication date. It does not constitute legal, financial, or medical advice. Practices should refer to the latest GMC, NHS England, and CQC guidance, and seek medico-legal advice where necessary.