Healthcare Fuzion Cart

HEALTHCARE FUZION CART CONSENT & CHECKOUT

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical History

Fuzion Cart Use — Procedure & Equipment Checklist

Device Model:    Serial Number:    Intended Use Date:

The Fuzion Cart will be used to store and deliver medications and supplies during clinical care. Patient consents to the presence and use of the cart in the clinical area and to authorized clinical staff operating cart equipment in the course of treatment.

Risks, Benefits, and Alternatives

I acknowledge that I have been informed about the nature and purpose of using the Fuzion Cart to facilitate medication administration and bedside procedures. Benefits include portable organized access to medications and supplies and streamlined clinical care. Risks include equipment malfunction, medication handling errors, accidental exposure to sharps or medication, and unforeseen adverse events associated with treatment. Reasonable precautions will be taken by clinical staff, but residual risk cannot be eliminated.

Alternatives to the use of the Fuzion Cart include conventional pharmacy-dispensed bedside carts or manual retrieval of medications; I have discussed alternatives with my clinician and understand the practical differences.

I acknowledge that I understand the benefits and risks described above and have had an opportunity to ask questions.

HIPAA — Privacy & Authorization

By signing below, I authorize the limited use and disclosure of my protected health information as necessary for the operation, maintenance, inventory, billing, and clinical documentation associated with care involving the Fuzion Cart. This authorization includes information necessary for medication administration records, incident reporting, and device maintenance logs.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. If not revoked earlier, this authorization will expire on the date indicated below or upon termination of the patient’s course of care, whichever occurs first.

Patient Responsibilities & Notices

The patient is responsible for informing clinical staff of any concerns about medications or device operation during care. The patient will not remove controlled medications or secured items from the cart. Lost or missing medications must be reported immediately; intentional removal or tampering with medications may result in civil or criminal liability.

Emergency procedures are in place in the event of equipment malfunction. Clinical staff will document any incidents involving the cart. This consent does not waive any rights related to negligence or malpractice; it documents informed consent specific to use of the device during care.

Sign Now