Palliative Care Education Video Consent Form
Please provide your information and consent to participate in the palliative care education video.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Role in Palliative Care
*
Please Select
Patient
Family Member
Healthcare Provider
Student
Other
I confirm that I have read and understood the information about the palliative care education video. I voluntarily consent to participate and allow my image and/or voice to be recorded and used for educational purposes. I understand that my participation is voluntary and that I may withdraw consent at any time by contacting the organizers.
*
I Agree
I Do Not Agree
Signature (please sign below to confirm your consent)
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: