Title: Medication guidance consent template
Subject: Medication guidance consent templte
Author: Bev Tivey;Julie Westwell
Last saved by: Aidan Newman
Company: Kirklees Council
Keywords: homecare; medication guidance; medication; domiciliary care

Consent (Template)

Provider name: ………………………………………………………………………………………………………………..…..
Service User name: (please print) ………………………………………………………………………………………….
Address: ……………………………………………………………………………………………………………………………….

A)	Written consent
I confirm that I give consent to staff supporting me with my *care/*care and medication support needs according to my support plan. (*Delete as appropriate) 

Signature …………………………………………………………………………………………………………………….……..….
Date ……………………………………………………………………..……………………………………………………………….

B)	Verbal consent 
The above named service user is able to make their own decisions but unable to sign consent due to (reason)………………………………………….……………………………………………………………………………….
Verbal consent has been given for staff to support with *care/*care and medication support needs according to my support plan. (*Delete as appropriate) 

Name and Signature of assessor/provider ……………………………………………………………………………
Date ………………………………………………………………………………………………………………………………………

C)	Unable to consent
I confirm that I have ‘Lasting Power of Attorney’ and am legally able to sign on behalf of the above named person. I give consent to staff supporting the above named service user with *care/*care and medication support needs according to the support plan. (*Delete as appropriate).
I understand the provider will require a copy (or to see a copy) of any legal documentation confirming that I am legally entitled to sign on behalf of the above named person. 

Name and Signature ………………………………………………………………………………………………….………
Date ……………………………………………………………………………………………………………………………...….

Please note: There are 2 types of Lasting Power of Attorney (POA)
•health and welfare
•property and financial affairs
POA for Health and Welfare MUST be in place for a person to legally make decisions for a service user. 
The provider must make a record of the date the POA was seen and the date the POA was legally approved. 
If a service user does not have capacity to consent or is unable to make certain decisions about their care and medication support and there is no POA in place, the provider will need to carry out a best interest assessment/decision, if one has not already been done. Evidence of any best interest assessments must be retained on the service user’s file. 
  
Full name and signature of provider assessor: 
Name/Signature ……………………………………….….…………………………..……………………………….
Job title ………………………………………………………………………………………………………..……………
Date ………………………………………………………………………………………………………………………….

V2.2022.Review July 2024
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