Hospital Patient Video Monitoring Consent Form
Please review and complete this form to acknowledge and consent to video monitoring in the hospital setting.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Room or Unit Being Monitored
*
Relationship to Patient
*
Please Select
Self
Parent/Guardian
Spouse/Partner
Other Family Member
Other
Reason for Video Monitoring (Select all that apply)
*
Patient safety
Security
Clinical observation
Other
Please acknowledge that you understand the purpose and scope of video monitoring in the hospital setting.
*
I understand and acknowledge
I do not understand
Consent to Video Monitoring
*
I consent to video monitoring as described
I do not consent
Signature of Patient or Authorized Representative
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: