Medical Supervision Fasting Consent Form
Personal Information
Full Name:
Date of Birth:
Contact Number:
Address:
Medical History
Please list any current medical conditions:
Please list any medications currently being taken:
Fasting Details
Type of fasting:
Planned duration of fasting:
Consent & Acknowledgments
I have discussed the nature and purpose of fasting under medical supervision with my health care provider.
I understand and accept the potential risks and benefits of fasting.
I confirm I will inform my medical supervisor of any concerning symptoms during fasting.
I voluntarily consent to participate and follow medical instructions during the fasting period.
Emergency Contact Information
Name:
Relationship:
Phone Number:
Participant Signature:
Date:
Medical Supervisor Signature:
Date: