Healthcare Safety Agreement

HEALTHCARE SAFETY AGREEMENT

Patient Name:    Date of Birth:    Medical Record/ID:

Patient Contact & Emergency Information

Insurance & Billing

Medical History — Patient Declaration

Safety Measures, Screening & Infection Control

The undersigned acknowledges that the healthcare facility maintains safety protocols to reduce transmission of communicable diseases. Patient agrees to comply with all reasonable facility policies while on premises, including but not limited to masking, hand hygiene, physical distancing, and screening procedures.

Presently experiencing any of the following symptoms? Fever, cough, shortness of breath, sore throat, new loss of taste or smell, vomiting, or diarrhea: Yes No

I consent to such screening for communicable diseases and to temperature checks and testing when clinically indicated. I understand that a positive screening or test result may result in deferred treatment or transfer to a designated area for infection control.

Facility Obligations & Limitations

The facility will use reasonable and customary infection control measures, personal protective equipment, and environmental cleaning procedures. These measures reduce but do not eliminate all risk of transmission. The facility does not warrant that all risk of transmission can be eliminated.

In the event of documented exposure to a communicable disease during a visit, the facility will notify exposed individuals as required by law and applicable policy. The facility will not be liable for transmission resulting from willful noncompliance with facility safety protocols by the patient or their visitors.

Consent for Emergency Treatment & Release

If, in the judgment of attending clinicians, immediate treatment is necessary to prevent serious harm, I authorize such emergency medical care. I consent to the disclosure of necessary medical information to third parties in an emergency when required to obtain appropriate care or protect public health.

I authorize testing and isolation measures as clinically indicated. I decline testing (I understand services may be limited or deferred).

Representations, Warranties & Indemnity

By signing this Agreement I represent and warrant that the information provided herein is true and complete to the best of my knowledge. I will promptly notify the facility of any changes to my health status that may affect the safety of staff, other patients, or visitors.

I agree to hold harmless and indemnify the facility, its employees and agents from claims arising from my failure to observe facility safety rules or to provide accurate health information, except to the extent caused by the facility's gross negligence or willful misconduct.

Privacy & HIPAA Acknowledgment

I acknowledge that I have been offered access to the facility's Notice of Privacy Practices describing the use and disclosure of my protected health information. I understand that my health information may be used and disclosed for treatment, payment, and healthcare operations as described in that notice.

I acknowledge receipt of the privacy notice. I decline receipt at this time.

Term, Revocation & Expiration

This Agreement is effective as of the date signed and remains in force for care provided at the facility until revoked in writing. Revocation does not affect actions taken in reliance on this Agreement prior to receipt of written revocation.

Acknowledgement of Risks

I understand that delivery of healthcare services involves certain risks, including but not limited to exposure to infectious agents. By signing below I acknowledge these risks and agree to follow reasonable precautions required by the facility.

I understand and accept the risks. I do not accept the risks (I understand this may limit available services).

Additional Instructions / Special Precautions

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