Signature: ________________ Date_____________ Time_______________ Patient Signature: _________________ Date: _______________ Time_____________ Authorized Healthcare Professional obtaining and witnessing patient’s signature Signature: ____________________________ Date______________: Time__________-_ Attending physician (if applicable) To be used if the patient is a minor, unconscious, or otherwise lacking decision making capacity. I, ___________________, the ________________ of ______________________hereby give consent Relationship to patient Signature: _________________ Date: _____________Time _______________ Legally Authorized Representative Signature: ________________________________ Date: _____________ Time _____________ Authorized Healthcare Professional obtaining and witnessing representative’s signature Signature: _______________________ Date:____________ Time _________ Attending physician (if applicable) Date: Time Date: Time Signature: Witness to telephone consent |