End-Stage Renal Disease Palliative Consent Form
Patient Information
Patient Name:
Date of Birth:
Medical Record Number:
Palliative Care Discussion
Risks, Benefits, and Alternatives
Patient/Representative Acknowledgement
I have had the opportunity to discuss my diagnosis, prognosis, care options, and goals with my medical team.
My questions about end-stage renal disease and palliative care have been answered.
I consent to initiate palliative care for end-stage renal disease.
Patient/Representative Signature
Date:
Provider Signature
Date: