- Home Environment Safety Consent Form-

Home Environment Safety Consent Form
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Home Environment Safety Agreement & Provider Protection Consent
Purpose of This Agreement
PNW Wound Specialist LLC provides mobile medical services in patient homes, residential facilities, and community settings. Our providers, including Physician Assistants, Registered Nurses, and supervising physicians, must be able to perform medical care in a safe, professional environment.

This agreement ensures that both patients and providers understand the safety expectations required for home-based care.
Patient Responsibilities — Safe Environment Requirement
Please help us prepare a safe place for your visit:
- Keep the path and care area clear of immediate hazards and provide reasonable access to the patient.
- Avoid threats, harassment, or aggressive behavior toward anyone at the visit.
- Secure pets away from the care area. Tell us beforehand if you use a service animal so we can plan reasonable accommodations.
- Secure firearms and other weapons away from the care area.
- Provide enough lighting and a reasonably clean area for safe wound care. Let us know if you need help preparing the space.
- Avoid smoking, vaping, or activities that create an immediate safety risk during care.
Contact us before the visit about mobility, communication, housing, or safety concerns. We will discuss practical adjustments or another appropriate care setting.
Provider Right to Leave or Discontinue Care
A provider may stop a visit and leave immediately if there is a threat or an immediate safety hazard. We will document the concern and, when safe, discuss how to resume care, reschedule, or arrange an appropriate alternative setting.

If we must end the ongoing care relationship, we will follow applicable professional requirements for notice, urgent care needs, records access, and transition to another provider. Immediate threats may require different safety arrangements. This agreement does not waive patient rights or allow abandonment.
Non-Emergency Medical Service Acknowledgment
PNW Wound Specialist LLC provides scheduled medical care and is not an emergency service provider.

If a medical emergency occurs, the patient agrees to call:

911 or local emergency services immediately
Compliance and Professional Care Statement
We share responsibility for respectful, safe care. Tell us about barriers so we can discuss reasonable accommodations and a workable care plan. You may ask questions or request a copy of this agreement.
Patient Acknowledgment and Consent
I understand the visit safety expectations, the emergency instructions, and the process for addressing an unsafe visit. I agree to work with the care team on a safe care setting.

The patient or a legally authorized representative may sign. A helper or emergency contact is not automatically authorized to consent. If a representative signs, identify their name and legal authority below; the care team will verify that authority.
Patient Name
Patient or Authorized Representative Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
OR
Authorized Representative Name
Complete only if a legally authorized representative signs for the patient. Staff will verify authority.
Representative relationship and legal authority (if applicable)
For example: health care power of attorney or court-appointed guardian. A family relationship alone does not establish authority.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Home Environment Safety Consent Form

Home Environment Safety Agreement & Provider Protection Consent

Patient Responsibilities — Safe Environment Requirement

Provider Right to Leave or Discontinue Care

Non-Emergency Medical Service Acknowledgment

Compliance and Professional Care Statement

Patient Acknowledgment and Consent