Hospital Surrogate Consent Form

Hospital Surrogate Consent Form
Please complete this form to document the authority of a surrogate decision-maker and provide relevant contact details for the patient.
Patient Full Name
First NameLast Name
Patient Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Surrogate Full Name
First NameLast Name
Relationship to Patient
Surrogate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Surrogate Email Address
example@example.com
Surrogate Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Alternate Contact Name
First NameLast Name
Alternate Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: