Section E: Patient / Next of Kin Consent Form and Indemnity
I hereby give my permission for Helderberg Hospice to be involved in my or my family member’scare and agree that the members of the Palliative care team may visit me / my family member. I give permission for the Hospice Staff to transport medication on my behalf when necessary. I agree and accept that, in my capacity as patient / member of the patient’s family, I will not hold any staff member or volunteer representing Helderberg Hospice liable for any harm suffered, loss incurred or injuriessustained by the patient or family member as a result of participation in caring for the patient at home, in transit or in the Support Centre.I hereby indemnify Helderberg Hospice against claims arising from the above by any Hospice employees, nursing staff and / or volunteers whilst making use of any facilities supplied by Helderberg Hospice.I agree that, Helderberg Hospice reserves the right to bill for services rendered which are not covered by the medical aid scheme, where applicable.Helderberg Hospice reserves the right to waive any fees associated with patient care where applicable.
Name of the person completing the consent and indemnity
E-mail address of the person completing the consent form
Capacity of person completing the consent and indemnity
Next of Kin / Spouse
Family Member (Other)
Signature of person completing the consent and indemnity
Consent and Indemnity signed at: (insert Region / District)
By providing Helderberg Hospice with your personal information and documentation, as set out herein, you voluntarily consent to it being reasonably retained, stored and processed. Your further acknowledge that such information is retained and processed for the lawful purposes and objectives of the organisation and that the information may be retained in a database to allow the organisation to communicate with you in future regarding prospective objectives / donations / interests. Such personal information will remain confidential and will not be shared with any third parties without your consent. All reasonable measures will be taken to safeguard your personal information. Should you object to our retention and processing of your personal information or should you wish to rectify your personal information retained with us, kindly inform us via e-mail at email@example.com
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm