Geriatric Care Treatment Agreement and Consent

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: ___________________

Agreement Terms

1. Consent for Treatment

I, _________________________, agree to receive geriatric care services from [Practice Name]. I understand that this may include:

• Comprehensive geriatric assessments
• Medication management
• Cognitive evaluations
• Functional status monitoring
• Care coordination services

2. Patient Rights and Responsibilities

Rights:

• Receive respectful, appropriate medical care
• Participate in treatment decisions
• Access medical records
• Confidentiality of health information
• Advance directive implementation

Responsibilities:

• Provide accurate medical history
• Follow agreed-upon treatment plans
• Attend scheduled appointments
• Inform provider of changes in condition
• Update advance directives as needed

3. Care Planning

I understand that my care plan will be developed collaboratively and may involve:

• Regular health assessments
• Medication reviews
• Specialty referrals
• Family/caregiver involvement
• Emergency care planning

4. Communication Authorization

I authorize communication regarding my care with: Name: _________________________ Relationship: _____________ Phone: _________________________

5. Financial Responsibility

I understand my financial obligations regarding:

• Insurance coverage
• Co-payments
• Non-covered services

Signatures

Patient/Representative: _____________________ Date: _________

Provider: _________________________________ Date: _________

Witness: __________________________________ Date: _________

Contact Information

Practice Phone: ___________________________ After Hours: _____________________________ Emergency: 911