Consult Registration Form

  • Consult Registration Form

    Please answer all the questions below and then choose an appointment date at the end to complete your registration.

  • Disclaimer: This service provides ethical guidance informed by Islamic bioethics principles. It is not a fatwa service and does not replace medical advice.

  • I consent to share the information provided below for the purpose of ethics consultation.*
  • Your Role with Respect to the Consultation*
  • How soon do you need guidance based on clinical decisions that need to be made?*

  • Your Information (Person Filling Out the Form)

    Enter your basic details below.
  • Format: (000) 000-0000.

  • Demographic Information of Patient

    Please enter in basic details below.
  • Primary Ethnicity of Patient*
  • Religious Affiliation of Patient*
  • If patient is Muslim, please specify sect

  • Health Conditions of Patient

    Please enter in basic details below.
  • Does the patient have any form of cancer*
  • Does the patient have renal disease?*
  • Is the patient on dialysis?*
  • Check off any other chronic medical diagnosis

  • Advance Care Directives

    Please enter in basic details below.
  • Does the patient have a designated healthcare proxy?*
  • Does the patient have a durable medical power of attorney naming a surrogate decision-maker?*
  • Does the patient have a 'Do Not Resuscitate (DNR)' or a 'Do Not Intubate (DNI) status?*
  • Does the patient have a Comfort Care or Hospice Care plan?*
  • Has the patient designated any preferences regarding organ donation?*
  • Are you familiar with death determination based on brain damage?*
  • Are you familiar with death determination based on cardiopulmonary collapse?*

  • Clinical Scenarios

    Please provide detailed responses below
  • Have you spoken to a religious scholar about this matter?*

  • Post Consultation Services:

    The consultation service typically consists of one or two 30-45-minute meetings with summary documents and decision aids (if available and needed) provided to you.

  • At this time, do you believe you may need any of the four options below?

  • A facilitated group meeting between multiple family members, or involving clinical team members, or religious advisors?*
  • Referral to a religious scholar for a fatwa specific to your situation?*
  • Connection with a Muslim healthcare chaplain for emotional, religious, and/or social support?*
  • Do you need help in filling out or creating advance care planning forms aligned to your religious sensibilities?*
  • Would you like an educational workshop for your community?*
  • Preferred Appointment Date and Time*
  • Should be Empty: