Symptom Management Palliative Care
Consent Form
Patient Information
Full Name
Date of Birth
Medical Record Number
Symptom Description
Describe Current Symptoms
Reason for Symptom Management Plan
Palliative Care Details
Planned Management or Interventions
Explanation Provided to Patient/Family
Consent
I have discussed the symptom management plan for palliative care, including benefits, risks, and alternatives. I consent to proceed with the recommended management.
Patient/Representative Name
Date:
Provider Name
Date:
Additional Comments