Healthcare Health Safety Forms

HEALTHCARE HEALTH SAFETY FORMS

Patient Information

Male Female Non-binary Prefer not to say

Emergency Contact

Insurance Information

Medical History & Current Health

Health Screening & Exposure

In the past 14 days, have you experienced any of the following? Check all that apply.

Fever or chills New or worsening cough Shortness of breath or difficulty breathing Sore throat Loss of taste or smell None of the above

Have you had close contact with a confirmed infectious disease case in the last 14 days?   Yes   No

Workplace Health & Safety Acknowledgment

I acknowledge that I have been informed of the facility's health and infection control policies and the required personal protective equipment (PPE). I understand these policies are designed to reduce the risk of disease transmission and that I must follow posted instructions and staff directions while onsite.

I acknowledge receipt of PPE and training where applicable. I agree to report symptoms or exposure immediately to the facility.

Consent for Treatment and Release

By signing below, I consent to receive routine and emergency healthcare services as determined necessary by clinical staff. I authorize personnel to perform examinations, administer treatment, and provide or arrange for emergency care. I understand that all procedures and treatments will be explained to me as appropriate and that I retain the right to refuse or withdraw consent at any time except as otherwise provided by law.

I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the release of medical information necessary for treatment, payment, or healthcare operations and attest that I am the patient or authorized to sign on the patient’s behalf.

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information. I understand that I may request restrictions on disclosures and inspect and copy my health information in accordance with applicable law.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights.

Vaccination / Immunization (if applicable)

Patient Certification

I certify under penalty of perjury that the information provided in this Healthcare Health Safety Forms document is accurate and complete to the best of my knowledge. I understand that false statements may result in denial of services or other actions permitted by law. I understand my rights to withdraw consent and my obligation to notify the facility promptly of any changes in my health or exposure status.

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