Hospital Treatment Guardianship Consent Form
Patient Information
Full Name
Date of Birth
Patient ID / MRN
Address
Guardian Information
Guardian Name
Relationship to Patient
Contact Number
Address
Legal Authority (type of guardianship)
Treatment Information
Treatment/Procedure Description
Doctor / Provider Name
Consent
I, as the lawful guardian of the above-named patient, hereby consent to the medical treatment/procedure as described above. I have had the opportunity to ask questions and understand the information provided by the medical team.
Guardian Signature
Date
Witness Name
Witness Signature
Date