Hospital Patient Food Delivery Consent Form
Patient Name
Room Number
Date of Birth
Admission Date
Dietary Restrictions / Allergies
Restaurant / Food Source
Food Description
I understand that external food may not meet hospital dietary or safety standards.
I accept responsibility for any risks or adverse events related to the consumption of external food.
Patient/Representative Consent
Signature
Date
Printed Name
Staff Use Only
Staff Name
Signature
Date