4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
Appendix L
CONSENT TO DIAGNOSIS, TREATMENT AND CARE
I, the undersigned, do hereby authorize the physician and employees of BC Transplant (and persons
authorized by such other institutions as may be requested by BC Transplant) to carry out examinations,
procedures and treatment deemed necessary and advisable for the evaluation, diagnosis, treatment and
continuing care. I, hereby authorize the release of follow-up information pertaining to my condition and/or
status (including medical diagnosis and relevant dates).
Program: ________________________________________
Registration Date: _________________________________
Name: (Mr., Mrs., Ms.) __________________________________________________________________
SURNAME
GIVEN NAMES
Date of Birth: _____________________________________________Sex:__________________________
MONTH DAY YEAR
Address: ______________________________________________________________________________
NUMBER
STREET
Address:_______________________________________________________________________________
CITY
PROVINCE
Address: ____________________________
POSTAL CODE
Telephone Number (home): (________)__________________ PHN:_____________________________
SIGNATURE:_________________________________
(PATIENT OR GUARDIAN)
WITNESS:____________________________________
(SIGN)
_____________________________________
(PRINT NAME IF NOT THE PATIENT)
_____________________________________
(PRINT NAME)
DATE: ___________________________________
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 56
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