Consent form

Dysphagia informed consent

Progress saves automatically to this device.

Fields marked * must be completed to continue.

Patient & Capacity

Record the facility, providers, and capacity determination.

Protected health information (PHI)

Heads up — anything you type here is saved to this browser only. Names, MRNs, and other identifiers will be stored locally on this device. Use the “Clear my data” option in the footer when you’re done on a shared device.

Facility & providers

Facility name*

Setting type*

Primary MD

Referring SLP

Capacity determination

Who will be making the informed-consent decision? required

Capacity assessment notes

Avoid direct identifiers (name, DOB, MRN) — keep notes clinical.

Saved