STUDENT______________________

EXAMINER______________________

Consent to Treat – Marking Sheet Nature Outcome of assessment/areas to be treated /purpose/draping ____ Cost Fee for today’s treatment ____ Benefits
What are the likely positive results of treatment? Risks What are possible side effects of treatment? Consequences What are the ramifications of not having treatment? Empowerment That patient can stop or modify the treatment at any time. ____ ____ ____ ____

Client care That therapist will be checking client comfort level periodically. ____
Alternatives Client made aware of other health care possibilities Oppurtunity for Questions Therapist asks if there are any questions/allow time Specific Request “Do I have your consent to perform this treatment?” ____ ____ ____

TOTAL

/10

COMMENTS

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