Care Agreement
This form contains facts you should know about your care and services from Wedgwood Geriatrics and Thanatology, Darrell A. Owens, DNP. If any part of this form is unclear, you can ask questions about it. At the bottom of the form is a place for you to sign your name so that I know you have read this form (or had it read to you) and agree to receive my services.
Dr. Darrell Owens, DNP, is a nurse practitioner licensed by the Washington State Board of Nursing. He is certified in adult health-primary care, gerontological and geriatric advanced practice nursing, advanced hospice and palliative care, and thanatology (provision of counseling and education services related to death, dying, and bereavement). Dr. Owens will provide services, as requested, that fall within the areas outlined above. Sometimes, your care is provided via telemedicine technology, which means a live video between you and Dr. Owens.
Services provided by Wedgwood Geriatrics and Thanatological Consulting may include patient consultation and education related to palliative or hospice care. This may include assessment, diagnosis, review of records, and, if appropriate, prescribing of medications or services. Additional services may include counseling and support services related to grief, loss, death, and dying.
Upon request, and if appropriate, Dr. Owens may provide consultative services related to the Washington State Death with Dignity law, also known as Medical Aide in Dying (MAID). These services may include telemedicine appointments, review of medical records, and, if appropriate and requested, prescribing medication related to participation in the law.
Signature
By signing below, you confirm that you have read this document and agree to receive one or more of the abovementioned services. If any part of this form is unclear, please ask questions.