Surrogate Decision-Maker Consent Form

Subject Information

Subject Name:

Date of Birth:

Study/Procedure Name:

Surrogate Information

Surrogate Name:

Relationship to Subject:

Address:

Phone Number:

Legal authority for decision-making (e.g., healthcare proxy, next of kin):

Consent Statement

I have read and understand the information provided about the study/procedure. The nature, purpose, risks, and potential benefits have been explained to me. I have had a chance to ask questions.

I give my consent, as the surrogate decision-maker, for the subject named above to participate in the described study/procedure.

Signatures

Surrogate Signature:

Date:

Witness Signature (if required):

Date:

Investigator/Staff Acknowledgment

Name:

Signature:

Date: