Nursing Home Informed Consent for Treatment
Nursing Home Informed Consent for Treatment
This form is designed to ensure that you, as a resident [Your Company Name], fully understand the proposed treatment plan and have the opportunity to make an informed decision regarding your care. Please read the following information carefully and feel free to ask any questions you may have before signing.
Treatment Details
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Treatment |
Description |
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Purpose: |
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Benefits: |
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Risks: |
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Alternatives: |
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Complications: |
Resident's Signature:
I, [Resident's Name], hereby acknowledge that I have received and understand the information provided above regarding the proposed treatment plan. I have had the opportunity to ask questions and have received satisfactory answers to my inquiries. I consent to undergo the treatment described above.
[Date]
Witness Signature (if applicable):
I, [Witness' Name], hereby certify that I have witnessed the signing of this consent form by [Resident's Name].
[Date]
For Office Use Only:
Date and Time Consent Received: [Date and Time]
Name of Staff Obtaining Consent: [Staff Name]
