Healthcare LPN Packet

HEALTHCARE LPN PACKET

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Primary Care Provider:    Last Visit Date:

Allergies & Alerts

Latex Allergy: Penicillin Allergy: Contrast Dye Allergy:

Immunizations

Nursing Assessment (to be completed by LPN)

Date of Assessment:    Time:

Temperature:    Pulse:    Respirations:

Blood Pressure:    SpO2:    Pain (0-10):

Consent for Treatment & Authorization

I, the undersigned, authorize licensed practical nurses (LPNs), registered nurses, physicians, and other authorized clinical staff to provide assessment, routine nursing care, medication administration as ordered, and other therapies that are standard to the care setting. I understand that:

1. All procedures and treatments will be explained to me in language I can understand and I may ask questions prior to initiation of care.
2. I have the right to refuse any treatment or medication to the extent permitted by law; refusal may affect my treatment outcomes and the clinical team will document and notify ordering providers where appropriate.
3. During provision of care risks and benefits of specific procedures will be identified and discussed when applicable; routine nursing procedures carry risks such as infection, bleeding, allergic reaction, or treatment failure depending on intervention.
4. This consent includes sharing necessary medical information with other treating providers and ancillary services to ensure continuity of care.

I authorize the release of my protected health information to persons involved in my care and to insurer(s) for payment and care coordination as needed. I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

Communications & Consent Preferences

Patient may receive appointment reminders and limited clinical messages via:

Voicemail: Text Message: Email:

Patient Rights & Acknowledgement

By signing below, I acknowledge that I have received sufficient information to make informed decisions regarding my care, that my questions have been answered, and that I have been provided with an opportunity to review privacy practices and patient rights applicable to this care setting. I understand that I may request copies of my records and that unauthorized disclosure of my information is limited by law.

Additional Notes (LPN Use)

Certification: I certify under penalty of law that the information provided on this packet is true and correct to the best of my knowledge. I understand that falsification of information may affect treatment and insurance processing. I further acknowledge that I have been afforded an opportunity to ask questions and that a copy of this completed packet may be included in my medical record.

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