Advanced Cancer Palliative Care Consent Form

This form is intended to obtain your consent to receive palliative care services for advanced cancer. Please read the following information and discuss with your provider if you have any questions.

Patient Information

Full Name

Date of Birth

Medical Record Number

Palliative Care Description

Potential Benefits

Potential Risks/Side Effects

Alternative Options

Patient Acknowledgement

I have read and understood the above information.
I have had the opportunity to ask questions.
I understand that I may withdraw my consent at any time.

Patient/Representative Name

Relationship (if not patient)

Date

Signature

Witness Name

Date