Family Meeting Palliative Care Consent Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Meeting Details
Date
Time
Location
Attendees
Discussion Summary
Consent
By signing below, I acknowledge that I have participated in the family meeting regarding palliative care options, and that the information discussed has been explained to my satisfaction. My questions have been answered.
Family Member/Representative Name & Signature
Relationship to Patient
Date
Healthcare Provider Name & Signature
Date