Patient: _______________________
 Consultant: ____________________
 Date/Time: _____________________
 
Person Requesting Consultation: _____________________
 
Attending Physician: _______________________________
Attending Participated in Consultation.  Yes ____   No ____
 
Reason for Consultation: ______________________________________________________________________________________

____________________________________________________________________________________________________________

Form of Consultation:

____ "On Call" Ethics Advisory Committee Member
____ Chair of the Ethics Advisory Committee
____ Ad Hoc Committee of the Ethics Advisory Committee
____ Full Ethics Advisory Committee

Individuals Involved in the Discussions: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Other Individuals to be involved in the Discussions: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Matters Discussed in the Consultation: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Agreements Reached in the Consultation: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Additional Matters to be Investigated/Discussed: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Reflections/Suggestions of the Consultation Effort: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________