Patient Informed Consent / Refusal (Oregon Department Of Corrections) (Page 5 of 8) in pdf

Patient Informed Consent / Refusal (Oregon Department Of Corrections) Page 5

P&P P-I-05

Attachment A

Oregon Department of Corrections

IMPORTANT

Sign only in one place after carefully reading entire form.

PATIENT INFORMED CONSENT / REFUSAL

has explained to me in a way

(Date)

(Name of provider)

that I understand:

1. The general treatment or procedure to be undertaken:

2. There may be other procedures or methods of treatment; and

3. There are risks to the procedure or treatment proposed.

My provider has also asked if I want a more detailed explanation; but I am satisfied with the explanation

and do not want any more information. I give my permission and consent to the treatment or procedure.

(DATE)

(PATIENT’S SIGNATURE)

After explanation of the procedure or treatment, other alternative procedures or

methods of treatment and information about the material risks of the procedure or

treatment, I give my permission and consent to the procedure or treatment.

(DATE)

(PATIENT’S SIGNATURE)

After explanation of the procedure or treatment, other alternative procedures or

methods of treatment and information about the material risks of the procedure or

treatment, I do NOT give permission and consent to the procedure or treatment.

(DATE)

(PATIENT’S SIGNATURE)

Explained by me and signed in my presence:

(PROVIDER)

(DATE)

(WITNESS)

(DATE)

Name:

SID#:

DOB:

CD490H (10/06)

Patient Informed Consent / Refusal (Oregon Department Of Corrections) Page 5