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Cherry Creek School District
Tube Feeding/Treatment Authorization Form
Students Name Date of BirthStudent #SchoolSchool Fairfax Numbers form provides health care provider and parental authorization
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How to fill out tube feeding authorization form
How to fill out tube feeding authorization form
01
To fill out a tube feeding authorization form, follow these steps:
02
Start by providing your personal information such as name, date of birth, and contact details.
03
Indicate the reason for requiring tube feeding, whether it is due to a medical condition, surgery, or any other relevant reason.
04
Specify the type of tube feeding required, such as nasogastric (NG) tube, gastrostomy (G-tube), or jejunostomy (J-tube).
05
Include information about the healthcare professional who will be responsible for managing the tube feeding. This may include their name, contact details, and any other relevant information.
06
If applicable, provide details about the healthcare facility where the tube feeding will be administered, including the name, address, and contact information.
07
Include any specific instructions or dietary restrictions related to the tube feeding, such as the type of formula or medication to be administered through the tube.
08
Review the form for accuracy and completeness before submitting it.
09
Sign and date the form to indicate your consent and understanding of the information provided.
10
Submit the completed form to the relevant healthcare provider or facility.
11
Note: The specific requirements and format of a tube feeding authorization form may vary depending on the healthcare provider or facility. It is important to follow their instructions and guidelines when filling out the form.
Who needs tube feeding authorization form?
01
A tube feeding authorization form is typically required for individuals who are unable to consume adequate nutrition orally and need to receive nutrition through a feeding tube.
02
This may include individuals who have difficulty swallowing, have certain medical conditions that affect their ability to eat or digest food, or have undergone surgery that requires tube feeding for a period of time.
03
Such individuals may include patients in hospitals, nursing homes, or other healthcare facilities, as well as those receiving home healthcare services.
04
The form ensures that healthcare providers have the necessary consent and information to safely administer tube feeding and manage the associated care.
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What is tube feeding authorization form?
Tube feeding authorization form is a document used to give consent for a person to receive nutrition through a feeding tube.
Who is required to file tube feeding authorization form?
The legal guardian or healthcare proxy of the individual who needs tube feeding is required to file the form.
How to fill out tube feeding authorization form?
The form must be completed with personal information of the individual, details of the healthcare provider overseeing the tube feeding, and the type of nutrition to be provided.
What is the purpose of tube feeding authorization form?
The purpose of the form is to ensure informed consent for the use of a feeding tube to provide necessary nutrition.
What information must be reported on tube feeding authorization form?
The form must include personal information of the individual, details of healthcare provider, type of nutrition, and any relevant medical conditions.
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