Lakewood Animal Hospital - Surgery Consent Form

Lakewood Animal Hospital - Surgery Consent Form

Volunteer Application

Adult over the age of 19 years
Applicant Name*

FirstLast Name
Applicant Phone Number*
Please enter a valid phone number.
Applicant Email*
example@example.com
In exchange for participation in the activity of observing and shadowing hospital staff organized by Lakewood Animal Hospital P.C. Ltd. (Lakewood Animal Hospital), of 1151 Lakewood Court North, Regina, Saskatchewan, S4X 3S3 and/or use of the property, facilities and services of Lakewood Animal Hospital, I agree to the following:
1. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Lakewood Animal Hospital, or the employees, representatives or agents of Lakewood Animal Hospital.*

YES, I agreeNO, I do not agree
2. I recognize that there are certain inherent risks associated with the above activity and I assume full responsibility for personal injury to myself, and further release and discharge Lakewood Animal Hospital for injury, loss or damage arising out of my use of or presence upon the facilities of Lakewood Animal Hospital, whether caused by the fault of myself, Lakewood Animal Hospital or other third parties.*

YES, I agreeNO, I do not agree
3. I agree to indemnify and defend Lakewood Animal Hospital against all claims, causes of action, damages, judgements, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my use or presence on the facilities of Lakewood Animal Hospital.*

YES, I agreeNO, I do not agree
4. I consent to the participation in observing and shadowing hospital staff, and agree to all the terms and conditions of this Agreement.*

YES, I consentNO, I do not consent
5. I agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire.*

YES, I agreeNO, I do not agree
6. I understand that even though I am not providing direct patient care at Lakewood Animal Hospital, I will see and hear confidential information about patients and clients of Lakewood Animal Hospital. ('Confidential information' includes any information learned while at the hospital, either verbal or written, paper or electronic.) I understand that ANY information about patients and clients is private - that means it must NOT be shared with others without written consent of the individual client. I understand that even the fact that a patient is in the hospital is a confidential piece of information - I am not allowed to share this with anyone else, including my family. Breach of confidentiality is grounds for immediate dissmssial and/or legal action.*

YES, I understand and I will not share confidential information about clients and patientsNO, I do not understand
In the event of a medical emergency while I am volunteering for the Lakewood Animal Hospital, I authorize whatever emergency medical treatment is deemed essential by responsible medical attendants.*

YES, I agreeNO, I do not agree
Emergency Contact Name and Phone Number*
I am over 19 years of age. The legal age of majority in Saskatchewan.*

YES, I agreeNO, I do not agree
I, the undersigned, understand that by signing this Release of Liability, I represent that I have read this document and I understand that by signing this release, I voluntarily surrender certain legal rights.*

YES, I understand and agreeNO, I understand and agree
Applicant Name*

First NameLast Name
Applicant Digital Signature*

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