Nursing Home Legal Consent
Form for Nursing Home Services

Please read this form carefully to understand the services being provided and the legal implications of consenting to such services. Complete and sign this form to indicate your agreement to receive our services under the terms outlined.

Resident Information

Name
Date of Birth		Room No.

Consent to Medical and Nursing Care Services

I, the undersigned, hereby give my consent to receive medical and nursing care services provided by the staff of this facility. I understand that this care may include but is not limited to:

• Routine diagnostic procedures

• Medical treatment as prescribed by the attending physician

• Nursing care and related health services

Acknowledgment of Information Received

I acknowledge that I have received information regarding:

• The nature and purpose of the treatment and services

• Possible alternatives to the proposed treatment

• The risks and benefits of the treatment and services

Voluntary Participation

I understand that my consent is given voluntarily and that I have the right to withdraw consent at any time.

Privacy and Confidentiality

I acknowledge that our organization respects the privacy and confidentiality of all personal health information. I consent to the collection, use, and disclosure of my health information as necessary for my care.

Consent to Non-Emergency Procedures

I also consent to the performance of non-emergency procedures as deemed necessary by my healthcare providers. This may include, but is not limited to, physical therapy, nutritional interventions, and routine medical examinations.

Use of Information for Quality Improvement

I agree that my health information may be used for quality improvement purposes within the facility to enhance the care provided to all residents.

Resident

[Name]

[Date]

Legal Representative

[Name]

[Date]

Staff Witness

[Name]

[Date]

By signing this form, you confirm your understanding and consent to the care and services provided by our organization. We are committed to providing high-quality care that respects the dignity and rights of all our residents. Thank you for trusting us with your care needs.

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