Certification of Incapacity

To Give Informed Consent

Make Health Care Decisions

Re:__________________________________,
 (Patient’s name)

I, Dr._____________________________________, have evaluated the above patient and determined that

 he/she lacks the capacity to give Informed consent and make health care decisions.  My evaluation of such is stated

 below:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

______________________________________                   _________________

       Attending Physician’s Signature                                              Date