ALS Palliative Care Consent Form

Patient Information

Patient Name Date of Birth Medical Record Number

Palliative Care Plan Summary

Summary of Care Plan

Discussions

Topics Discussed (select all that apply): Goals of Care
Symptom Management
Advance Directives
Other

Consent Confirmation

I confirm that I have discussed the palliative care plan for ALS, understand the options and have had all my questions answered.

Patient/Legal Representative Name Relationship (if not patient) Date

Healthcare Provider Name Date