Dementia Palliative Care Consent Form
Patient Information
Patient Name
Date of Birth
Address
Diagnosis & Condition
Dementia Diagnosis
Other Relevant Medical Conditions
Palliative Care Information
Goals of Palliative Care
Treatments/Support to be Provided
Risks and Benefits Discussed
Consent Confirmation
I confirm the information has been explained and I understand the palliative care plan.
I agree to palliative care for the patient named above.
Patient/Representative Name
Signature
Date
Healthcare Provider Name
Signature
Date