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   Consent for Admission
I hereby request admission to Lisaard and lnnisfree Hospice for the purpose of receiving palliative end of life care. I understand that I will be cared for by an Interdisciplinary Health Care Team and that the following hospice palliative care personnel and services may be provided to me during the course of illness:
Physician, Nursing, Personal Support Workers, Social Work, Counseling services (Bereavement and Spiritual Care), Volunteers, Pharmacist, Legacy and Therapeutic Services and services provided by the Waterloo Wellington Local Health Integrated Network (WWLHIN).
Consent for Treatment
Initials.
___ I hereby give my permission for authorized personnel of Lisaard and lnnisfree Hospice to perform all necessary procedures and treatments for the delivery of hospice care.
___ I acknowledge and agree that no treatment or investigation to prolong my life, including cardiopulmonary resuscitation (CPR), will be carried out.
___ I understand that I may refuse treatment or terminate services at any time.
___ I understand I have a right to participate in planning my care and agree and consent to the care plan
___ I give permission to have my blood tested for Hepatitis B, C, and Human Immunodeficiency Virus (HIV) should a member of the Interdisciplinary Health Care Team inadvertently come in contact with my blood or body fluids.
___ I understand that should the Interdisciplinary Health Care Team determine that hospice palliative care is not my imminent and primary need, discharge planning will be initiated in coordination with myself, my power of attorney or substitute decision maker and the WWLHIN.
Authorization to Obtain and Release Information
___ I authorize Lisaard and lnnisfree Hospice staff to receive and release personal health information in accordance with Personal Health Information Protection Act, 2004 (PHIPA) as applicable to the provision of my care. I agree that my Personal Health Information can be used by Lisaard and lnnisfree for the purpose of Quality Improvement including Accreditation.
___ I understand that all personal belongings that I bring into the hospice are my responsibility and Lisaard and lnnisfree Hospice is not responsible for lost, damaged or stolen items.
Advance Directives
___ I understand that I have the right to make health care decisions for myself and that I may appoint a Power of Attorney (POA) to make health care decisions on my behalf when I am unable. Alternately, I understand that if I do not appoint a POA a Substitute Decision Maker (SOM) will make health care decisions on my behalf (The Substitute Decisions Act, 1992 (SDA) and Health Care Consent Act, 1996 (HCCA)).
___ I have provided a copy of my POA for health care to Lisaard and lnnisfree Hospice
I do not have an appointed POA, my Substitute Decision Maker (as per the Substitute Decisions Act, 1992) is: .............................................................. Relationship to Resident: ...............................................
        I understand a copy of this consent form shall be as valid as the original and shall remain in effect until I am discharged from Lisaard and lnnisfree Hospice. I also understand that I may revoke this consent in writing at any time
  .......................................................................................... Resident Signature
.......................................................................................... Power of Attorney or Substitute Decision Maker Signature
....................................................................................... Date
....................................................................................... Lisaard and Innisfree Hospice Representative Signature












































































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