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DOMESTIC VIOLENCE DOCUMENTATION CONSENT FORM TO OBTAIN EVIDENCE To: And to: (Name of Domestic Violence Nurse) (Name of Hospital) I, authorize you to: (initial choices) Complete Domestic Violence documentation Collect articles of my clothing and/or physical samples for potential use as evidence Photograph my injuries for potential use as evidence I understand that I may consent to some, all or none of the above. Should I decline to consent to any of the above, I will not be denied medical treatment. I may withdraw my consent to any of the above at any time during the examination. I also understand that a child protection agency may be notified if there are children under the age of 16 witnessing violence in the home. Hospitals are also required to release records when subpoenaed through a court order including warrants, in accordance with relevant privacy legislation. Patient Name (please print) (Signature of Patient) (Date/Time) Witness Name (please print) (Signature of Witness) (Date/Time) Interpreter Name (please print) (Signature of Interpreter) (Date/Time) CONSENT FORM TO RELEASE EVIDENCE I, , authorize you to: (Initial choices) Inform police that I have made a complaint of assault. (Name of Police Services) Release to the police the forensic report of the SA/DV Nurse, with the exception of the safety and discharge planning ______ Release any clothing, physical samples, or photographs the SA/DV Nurse has collected (Signature of Patient) (Date/Time) (Signature of Witness) (Date/Time) (Signature of Interpreter) (Date/Time)  1. ADMINISTRATIVE INFORMATION NAME: D.O.B.: SEX: ? Female ? Male AGE: Do you have children under the age of 16? ? No ? Yes # ________ Name: Age: Name: Age: Name: Age: Client referred by: ? Family ? Shelter ? VWAP ? Police ? Victim Services ? Hospital___