Tray Audit Form - DOC

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Tray Audit Form - DOC Powered By Docstoc
					                          Waiver for Diet (Therapeutic Diet)
This is a sample. Please adjust as needed for your facility and print on facility letterhead.
             Consult your facility attorney or risk management department.




Patient Name_______________________           Patient Date of Birth____________

Medical Record Number:_______________


I, ______________________________ understand that the doctor has ordered a special
diet. This diet is considered important to my health and is part of my treatment plan.
However, I prefer to make my own food choices and wish to decline the
__________________ diet that was prescribed. My questions about the diet have been
answered. I have been counseled on the risks and benefits of refusing the diet and accept
responsibility for any health condition that may result from refusal of the diet. I release
______________________(facility name) of liability regarding this decision to refuse the
recommended diet.



Patient (or Responsible Party                                                        Date

________________________________________________________________________
Facility Representative                                           Date

________________________________________________________________________
Witness                                                           Date

				
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posted:6/24/2012
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