Healthcare Girls Waiver

HEALTHCARE GIRLS WAIVER

This Healthcare Girls Waiver (the Waiver) documents informed consent, authorization and release of liability for medical care of the minor female patient named below. The undersigned certifies that they are the parent or legal guardian authorized to execute this Waiver on behalf of the minor patient and that the statements made herein are true and complete.

Patient Information

Patient Name:    Date of Birth:    Gender:

Guardian / Responsible Party

Insurance Information

Medical History

Authorization and Consent

I, the undersigned parent or legal guardian, hereby authorize licensed medical personnel and designated staff to provide and administer routine and emergency medical care to the patient named above. This authorization includes, but is not limited to: examinations, basic diagnostic testing, administration of prescribed or over-the-counter medications, vaccinations, first aid, and transport to an appropriate medical facility when necessary. I understand that such treatment may carry potential risks and complications.

By signing below I acknowledge that I have been informed of the general risks and benefits associated with routine and emergency treatment. I understand that no guarantees have been made regarding the results of any care or treatment. I accept responsibility for notifying providers of any change in the patient's health or medication status prior to treatment.

Consents (check all that apply)

I consent to routine medical care and examinations.
I consent to emergency medical treatment and transfer to hospital if needed.
I consent to administration of medications as ordered by a licensed practitioner.
I consent to vaccinations required or recommended for participation in healthcare services, unless otherwise restricted above.
I consent to telehealth encounters when in-person care is not available.

HIPAA / Privacy Acknowledgment & Release

I acknowledge receipt of the provider's privacy practices and hereby authorize the release of medical information necessary for treatment, payment and healthcare operations. This authorization includes release to emergency responders, hospitals, and other treating clinicians. I understand that this authorization is voluntary and that I may revoke it in writing except to the extent that action has already been taken in reliance on it.

Release, Indemnity and Certification

To the fullest extent permitted by law, I release, discharge and hold harmless the healthcare provider, facility, program organizers, employees, agents, and volunteers from any and all liability, claims, demands, actions or causes of action arising out of or relating to any loss, damage or injury sustained as a result of the provision of authorized medical care, except for acts constituting gross negligence or willful misconduct. I agree to indemnify and defend the released parties from any third-party claims arising from my execution of this Waiver.

I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that falsification may result in denial of services and may subject me to legal penalties.

Additional Authorizations

Consent Acknowledgment

By signing below, I acknowledge that I have read and understand this Waiver, that I have had the opportunity to ask questions, and that all questions have been answered to my satisfaction. I understand that I may withdraw this authorization at any time by providing written notice, except insofar as action has already been taken in reliance on it.

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