Geriatric Care Treatment Plan Agreement
Patient Information
Patient Name
Date of Birth
Contact Number
Address
Emergency Contact
Name
Relationship
Contact Number
Treatment Plan
Diagnosis
Treatment Goals
Medications
Planned Procedures/Interventions
Follow-up & Review Schedule
Care Provider Information
Care Provider Name
Contact Number
Credentials
Consent & Agreement
I have reviewed and agree to the treatment plan described above.
Patient/Representative Signature
Date
Provider Signature
Date