Healthcare Food Agreement

HEALTHCARE FOOD AGREEMENT

This Healthcare Food Agreement documents the dietary orders, feeding assistance needs, risks, and authorizations related to provision of food, modified diets, or feeding assistance by the facility and its authorized staff. By signing this form the patient or authorized representative consents to the dietary plan and acknowledges the risks, responsibilities, and limits of liability described below.

Patient Information

Emergency Contact

Insurance Information

Medical & Dietary History

Swallowing difficulty or dysphagia: Yes No

History of aspiration or choking incidents: Yes No

Feeding tube in place: Yes No

Diet Orders and Preferences

Select prescribed diet texture and restrictions (multiple may apply):

Regular diet Soft diet Mechanical soft Pureed

Diabetic/carbohydrate-controlled Low sodium Low fat Gluten-free

Thickened liquids: Thin Nectar-thick Honey-thick

Feeding Assistance Needs

Level of assistance required (check all that apply):

Independent Supervision / prompting Partial assistance (help with setup or cutting) Full assistance (hand feeding)

Use of adaptive equipment (utensils, cups, etc.): Yes No

Outside Food & Special Requests

Are outside food items permitted to be brought or delivered to the patient? Yes No

Patient or representative acknowledges that food prepared outside the facility may not meet the facility's safety, nutritional, or preparation standards. The facility retains the right to refuse, withhold, or modify outside food that conflicts with medical orders or presents a health risk.

Risks, Benefits, and Alternatives

Risks: Provision of food and feeding assistance involves known risks including allergic reaction, choking, aspiration pneumonia, foodborne illness, and other complications. The patient or representative understands these risks and accepts them unless otherwise indicated by a treating clinician.

Benefits: Proper diet and feeding assistance intend to maintain or improve nutrition, hydration, comfort, and recovery. Modified textures, supervised feeding, and specialized diets reduce specific risks when ordered by clinical staff.

Alternatives: Alternatives include alteration of diet orders, escalation to tube feeding when clinically indicated, refusal of certain foods, or consultation with a dietitian or speech-language pathologist for swallowing management.

Facility and Patient Responsibilities

Facility responsibilities include: providing meals consistent with clinical diet orders when reasonably available, documenting food-related allergies and restrictions, offering feeding assistance consistent with assessed needs, and recording any adverse food-related events.

Patient/Representative responsibilities include: providing accurate and complete dietary and allergy information, adhering to prescribed diet orders while in the facility, informing staff of any new symptoms after eating, and following staff instructions related to feeding safety.

Privacy & Disclosure

The patient authorizes disclosure of dietary and related medical information to clinical staff, dietitians, speech-language pathologists, and other caregivers as necessary for safe provision of food services. Such disclosures are subject to applicable privacy protections.

I acknowledge that I have been informed of the facility's practices regarding disclosure of dietary and feeding information.

Authorization

I, the undersigned, authorize the facility and its authorized personnel to provide food, nutritional services, and feeding assistance consistent with the orders and preferences documented above. I understand and accept the risks set forth in this agreement.

Patient Name:    Date of Birth:

Authorization Expiration Date:

Right to Withdraw: This authorization may be revoked at any time by providing written notice to the facility, except to the extent that actions have already been taken in reliance on this agreement.

Liability and Indemnification for Outside Food: If outside food is permitted, the patient or representative assumes responsibility for food safety and indemnifies the facility against claims arising from consumption of outside food, except for claims resulting from gross negligence by the facility.

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