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(FHCDA) CONSENT FORM 2

(FHCDA) CONSENT FORM 2 2026

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The document outlines the procedures for enabling a surrogate to consent to treatment for an adult patient who lacks decision-making capacity, as per the Family Health Care Decision Act (FHCDA). It details steps for verifying the patient's incapacity, identifying a suitable surrogate, and informing them of their role in making healthcare decisions. Specific conditions under which this form should not be used are also provided.

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Click ‘Get Form’ to open the (FHCDA) CONSENT FORM 2 in the editor.
Begin by entering the Patient Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the Admission/Visit Date and Medical Record Number. This helps track the patient's treatment history effectively.
In the section for Determination of Incapacity, ensure that the attending physician or NP completes this step if applicable. They must confirm that the patient lacks decision-making capacity.
Identify and inform the surrogate by filling out their name and relationship to the patient. This is essential for ensuring proper consent is obtained.
Finally, have the attending physician or NP sign and date the form at the bottom to validate all statements made regarding incapacity and surrogate designation.

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