Geriatric Care Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________ Date: ____________________

Purpose of Consent

This document outlines the consent for geriatric medical care and treatment at [FACILITY NAME].

Consent for Treatment

I, _____________________, consent to receive medical care and treatment from the healthcare providers at [FACILITY NAME]. I understand that:

• Medical care may include examinations, tests, medications, and procedures
• Treatment plans will be discussed with me and/or my designated healthcare proxy
• I have the right to ask questions about my care at any time
• I can refuse specific treatments while consenting to others

Specific Authorizations

• Comprehensive Geriatric Assessment
• Cognitive Function Testing
• Fall Risk Assessment
• Medication Management
• Care Coordination Services

Healthcare Proxy Information

Name: _________________________ Relationship: ______________ Contact: _______________________

Financial Responsibility

I understand that:

• I am responsible for any charges not covered by insurance
• Medicare coverage and limitations have been explained to me
• I will be informed of any significant changes in costs

Signatures

Patient Signature: _________________ Date: __________

Healthcare Proxy Signature: _________ Date: __________ (if applicable)

Provider Signature: ________________ Date: __________

Witness

Signature: ________________________ Date: __________

Printed Name: ____________________