The Proxy Consent Form is a critical legal instrument in Nigerian healthcare practice that enables individuals to designate trusted representatives to make medical decisions on their behalf when they are unable to do so. This document becomes particularly important in situations involving temporary incapacity, emergency medical treatment, or long-term care planning. The form must comply with Nigerian federal legislation, including the National Health Act 2014 and relevant healthcare regulations. It typically includes detailed information about the scope of authority granted, the circumstances under which it becomes effective, and any specific limitations or preferences regarding medical treatment. The document serves as a crucial tool for healthcare providers, family members, and legal representatives in ensuring that patient wishes are respected while maintaining legal compliance.
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1. Identification of Parties: Details of the person granting proxy consent (the grantor), the designated proxy decision-maker, and any alternate proxies
2. Declaration of Capacity: Statement confirming the grantor's mental capacity and voluntary execution of the document at the time of creation
3. Scope of Authority: Detailed description of the medical decisions and healthcare matters the proxy is authorized to make decisions about
4. Duration of Authority: Specification of when the proxy consent becomes effective and when it terminates
5. Proxy's Obligations: Description of the proxy's duties and standard of care in making decisions
6. Execution: Formal requirements for signing, witnessing, and dating the document
1. Specific Medical Conditions: Include when the proxy consent relates to specific known medical conditions or treatments
2. Religious or Cultural Preferences: Include when specific religious or cultural considerations should guide medical decisions
3. Emergency Contact Information: Include when additional emergency contacts beyond the proxy need to be specified
4. Revocation Clause: Include when specific conditions for revocation need to be outlined beyond standard legal provisions
1. Schedule A - Medical History: Optional schedule containing relevant medical history and current conditions of the grantor
2. Schedule B - Specific Treatments: List of specific medical treatments or procedures for which proxy consent is explicitly granted or withheld
3. Appendix 1 - Identification Documents: Copies of identification documents for all parties involved
4. Appendix 2 - Medical Provider Information: List of current healthcare providers and medical facilities regularly used by the grantor
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