Pain Management Palliative Consent Form

Patient Information

Patient Name: Date of Birth: Medical Record Number:

Provider Information

Physician/Provider Name: Date:

Consent

I have been informed about my pain and palliative care treatment, including risks, benefits, and alternatives. I have had the opportunity to ask questions and they have been answered to my satisfaction. I understand that participation in this pain management/palliative care plan is voluntary.

Treatment Plan Summary

Summary of Planned Pain Management and Palliative Care:

Signature

Patient/Representative Name: Relationship to Patient (if Representative): Date:

Provider Signature

Provider Name: Date: