Healthcare Alcohol Prohibition Form

HEALTHCARE ALCOHOL PROHIBITION FORM

Facility Name:     Patient Name:

Date of Birth:     Gender:     Medical Record #:

Contact & Insurance Information

Medical History (Relevant)

Prohibition Terms & Testing

Effective From:     Authorization Expiration Date:

The patient affirms and agrees to the following prohibitions and conditions with respect to alcohol consumption and possession in connection with treatment at the facility. These prohibitions apply to any pre-procedure period, during facility admission, and until formally cleared by the attending clinician.

I will not consume alcohol within hours prior to any scheduled procedure or administration of sedative, anesthetic, or other medications that may interact with alcohol.

I will not possess, bring, or use alcoholic beverages on facility premises or otherwise consume alcohol during the period of admission or while under facility supervision.

I consent to on-site screening for alcohol impairment, including breathalyzer, urine, or blood tests, at the facility's discretion to determine fitness for treatment or admission.

I consent to collection of blood if clinically indicated or required by facility policy.

Risks, Consequences & Authority

I understand that alcohol consumption in proximity to medical procedures or while receiving sedative or analgesic medications increases the risk of respiratory depression, aspiration, bleeding, unpredictable hemodynamic effects, and other adverse events. The facility and attending clinicians are authorized to postpone, cancel, or discontinue treatment if alcohol use or impairment is suspected or confirmed.

I acknowledge that a positive screening or refusal of testing may result in: (a) deferral or cancellation of procedures or treatments; (b) discharge from the facility; (c) documentation in my medical record; and (d) potential financial responsibility for services rendered or for rescheduling fees. The facility may notify designated individuals for reasons of safety when necessary and permitted by law.

The facility and its clinicians are not responsible for adverse outcomes that result from failure to comply with this prohibition or from undisclosed alcohol use. I agree to indemnify and hold the facility harmless for actions taken in good faith under this policy, including those necessary to protect my safety or that of others.

Acknowledgements & Consents

I have read and understand the alcohol prohibition policy above and the associated risks. I will comply with the prohibitions and directives of the treating clinicians and facility staff.

I authorize the facility to perform alcohol screening and to use and disclose results to healthcare personnel and, where necessary for safety, to other relevant parties as permitted by law.

I understand I may withdraw consent to treatment at any time; however withdrawal of consent to this prohibition or refusal to comply may result in cancellation or discontinuation of care and will not prevent documentation of impairment in my medical record.

I acknowledge receipt of the facility's Notice of Privacy Practices and consent to use and disclosure of my protected health information as necessary to implement and enforce this alcohol prohibition and to protect health and safety.

Additional Instructions / Clinical Notes

Certification

By signing below I certify under penalty of perjury to the best of my knowledge that the information provided in this form is true and complete. I understand that noncompliance with this alcohol prohibition may result in postponement or denial of treatment and other actions described in this form.

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