Hospice Care Consent Form
Patient Name
First Name
Last Name
MR Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I, the patient, agree with the following statements:
I understand the care I received from the Hospice is not directed to extend the length of life or reversal of the disease that I am suffering. But, the Hospice program is directed to the greater degree of symptom control that includes the relief of pain, creation of an environment for myself and my family to relieve stress and promote support.
I understand that there won't be extraordinary life saving measures like cardiopulmonary resuscitation. I understand the limits of the program the hospice provided.
After entering the hospice program, I understand my attending physician will prescribe the extent and nature of my care and treatment and the hospice is not liable for any act or omission in following his instructions.
I give permission to the Hospice to obtain personal/medical information and release this information to any relevant health care organization or physician.
I consent to my care and treatment in the hospice program under the above conditions, and I hereby release the Hospice, its officers and employees from all liability regarding to program's limitations to relieve my pain and making me comfortable.
I have been given opportunity to ask questions that I have concerning the Hospice program.
I have been provided a document about my rights and responsibilities as a patient. I read and understand the document.
I have read and understand above statements and I have signed this consent as my own free will.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: