Healthcare Garden Care Form

Healthcare Garden Care Form

The undersigned authorizes supervised garden care, horticultural therapy, and related outdoor activities provided by facility staff or contracted personnel. Activities may include planting, pruning, weeding, light lifting, soil contact, tool use under supervision, and mobility assistance as needed. Patient Name:

Patient Information

Insurance Information

Medical History

Does the patient require mobility assistance for outdoor activities? Yes No

Garden Care Assessment

Typical garden care activities to be performed are described below. Staff will tailor activities to the patient's functional capacity. Activities include:

Indicate any tasks that should be avoided for medical reasons (e.g., heavy lifting, exposure to certain plants):

Risks, Benefits and Consent

I understand that garden care and horticultural activities involve inherent risks including, but not limited to, minor cuts, insect bites or stings, allergic reactions, sun exposure, slips, trips, falls, and exacerbation of preexisting conditions. I acknowledge that staff will take reasonable precautions, provide supervision, and modify activities to reduce risk.

I understand the potential benefits of participation, including improved physical activity, sensory engagement, psychological well-being, and social interaction. Participation is voluntary and may be discontinued by me or by staff if deemed in my best interest.

By signing below I consent to receive garden care services and acknowledge that I have disclosed relevant medical information. I release and hold harmless the facility, its employees, volunteers, and contractors from liability for ordinary negligence arising from participation, except where prohibited by law. I agree to indemnify against claims arising from my own actions during activities.

Authorization, Photography and Treatment

I authorize facility staff to provide routine assistance, first aid, and to arrange or provide emergency medical treatment if necessary. I authorize the use of photographs for internal program records only: Yes No

I understand this authorization is valid until: unless revoked in writing earlier. To revoke, submit a signed written notice to facility administration. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received a copy of the facility's Notice of Privacy Practices describing how protected health information may be used and disclosed in connection with treatment, payment, and healthcare operations. I understand my rights regarding health information and consent to the use of information necessary for coordination of garden care services.

I acknowledge receipt of the Notice of Privacy Practices

Emergency Procedures & Reporting

In the event of an injury or emergency, staff will provide immediate first aid, notify emergency contact, and arrange transport to appropriate medical services if required. All incidents will be documented in the facility incident report and reported to appropriate oversight personnel.

Additional Instructions / Provider Notes

Acknowledgment and Consent

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand the risks and benefits described and consent to participate in garden care activities under the terms set forth above. I further authorize staff to communicate necessary health information to personnel involved in my garden care.

Sign Now