Portable Equipment Responsibility

1

Who Is Completing This Form?* This field is required.

Patient

Spouse

Family Member

Caregiver

Friend

2

Why Is Patient Unable To Complete?

Patient physically unable

Patient cognitively impaired

Patient clinically unable to be disturbed

Patient is a minor

3

Who Is Completing The Form?

First Name

Last Name

4

Patient Name* This field is required.

First Name

Last Name

5

Date of Birth* This field is required.Please select your date of birth.

Date

6

Patient URN* This field is required.

7

Machine Number* This field is required.

8

Portable Equipment Responsibility* This field is required.

9

Instructions Acknowledgement/Consent* This field is required.

10

Device Operation* This field is required.I feel I can properly perform the tasks needed to operate the device I'm being provided.

YESNO

11

Patient/Representative Signature* This field is required.

12