Healthcare Oxygen Trolley

HEALTHCARE OXYGEN TROLLEY — EQUIPMENT ISSUE & PATIENT ACKNOWLEDGMENT

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other

Insurance Information

Medical History (Relevant to Oxygen Therapy)

Device Details — Oxygen Trolley Issued

Device Model:

Serial Number:    Cylinder Size:

Regulator Type:    Humidifier Attached:

Date Issued:    Issued By (Staff Printed Name):

Pre‑Issue Inspection Checklist (Staff to complete)

Cylinder pressure checked and adequate for immediate use

Regulator and flowmeter functioning normally

Tubing and connections intact, no kinks or visible damage

Humidifier (if applicable) clean and assembled per protocol

Instructions, Warnings & Patient Responsibilities

The oxygen trolley is prescribed for therapeutic use only. Patient must follow prescribed flow rate and administration method. Oxygen is a flammable medical gas: smoking, open flames, and combustible materials in proximity to the device are strictly prohibited. Failure to comply with safety instructions may result in fire, explosion, serious injury, or death.

Patient agrees to: (a) operate the equipment only as instructed; (b) keep cylinders secured and upright; (c) not attempt regulator repair; (d) inspect tubing and connections daily for leaks; and (e) immediately report malfunction, damage, or adverse effects to the issuing provider.

The issuing facility is responsible for routine maintenance and safety inspections. The patient or caregiver is responsible for safe operation in the home environment and timely return of the trolley and accessories on or before the arranged return date.

Consent, Acknowledgment & Authorization

By signing below the patient (or legally authorized representative) certifies that the information provided is accurate to the best of their knowledge, that the patient has received training in the use and safety of the oxygen trolley, and that the patient understands the risks, warnings, and responsibilities set forth in this document. The patient authorizes issuance of the listed equipment and agrees to maintain and return it in accordance with facility policy.

Patient understands they may withdraw this authorization and return the equipment at any time; withdrawal does not affect actions already taken in reliance on this authorization while it was in effect.

Privacy Acknowledgment (HIPAA)

I acknowledge receipt of the facility's privacy practices related to the disclosure and use of protected health information for the purpose of issuing and servicing this equipment. I consent to the use and disclosure of my health information as reasonably necessary to deliver, maintain, bill for, and otherwise manage the equipment provided.

I acknowledge and consent to the above privacy practices.

Return, Repair & Liability

Patient agrees to return the trolley and all accessories in clean condition by the agreed return date. Costs for loss, theft, or damage due to misuse may be charged to the patient. The issuing facility retains ownership of the equipment and liability for manufacture defects or failure of properly maintained equipment. Patient assumes liability for negligent operation or deliberate misuse.

Staff Issuance Record (For facility use)

Sign Now