Healthcare Chicken Soup Form

HEALTHCARE CHICKEN SOUP FORM

Patient Information

Patient Name:   Date of Birth:

Insurance Information

Medical History & Dietary Information

Allergic to poultry or ingredients: Poultry Eggs Gluten Other

Chicken Soup Request and Clinical Considerations

Request Purpose:   Preferred Serving Date:

Preparation Preferences (check applicable):
Low sodium Boneless Blended/pureed Gluten-free

Risks, Benefits, and Acknowledgments

I understand that provision of chicken soup by this healthcare facility is a comfort/nutritional request and not a substitute for prescribed nutritional therapy. Potential risks include, but are not limited to, allergic reaction, aspiration, interference with prescribed medical diets or medications, increased sodium or fluid load, and contamination risks inherent in food service.

I acknowledge that facility staff and clinical providers have reviewed my medical record for contraindications to oral intake and that clinical staff will refuse or modify this request if they determine it to be clinically unsafe.

I certify that the information I have provided on this form is true and complete to the best of my knowledge, and I authorize facility staff to provide the requested chicken soup in accordance with the preparation instructions and clinical determinations below.

Acknowledgement: I have read and understand the risks and statements above.

Right to Withdraw: I understand I may withdraw consent at any time by notifying nursing staff.

Clinical Determination (To be completed by clinical staff)

Clinician Review:   Date:

Clinical Determination (select one):
Approved as requested Approved with modifications (see notes) Denied due to clinical contraindication

Privacy and Authorization

I authorize the release and use of my medical and dietary information to staff involved in food preparation and clinical care for the purpose of evaluating and fulfilling this request. My health information may be disclosed only as necessary to carry out this request.

Authorization Expiration: This authorization will expire on:

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

Privacy Acknowledgment: I acknowledge that I have received and reviewed the facility privacy practices regarding use of protected health information for this request.

Certification and Signature

By signing below I certify that I am the patient or the patient's legal representative, that I have authority to make this request, and that all information provided on this form is accurate and complete to the best of my knowledge. I consent to the provision of chicken soup as described above subject to clinical review and facility policies.

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