Consent to Treatment by Volunteers in Medicine Staff and Volunteer Medical Professionals
I understand that services I receive from Volunteers in Medicine providers is free of charge.
I understand that state and federal law imposes a limitation on the recovery of damages from such a volunteer clinic in exchange for receiving health care services. Those limitations include immunity from civil liability for any act or omission resulting in death or injury to a patient if:
1. The employee and/or volunteer was acting in good faith and in the course and scope of the provider's duties or functions within the organization;
2. The employee and/or volunteer commits the act or omission in the course of providing health care services to the patient;
3. The services provided are within the scope of the license of the employee and/or volunteer; and before the employee and/or volunteer provides health care services, the patient (or if the patient is a minor or is otherwise legally incompetent, the patient’s parent, legal guardian, or other person with legal responsibility for the care of the patient) signs a written statement that acknowledges;
a. That the employee and/or volunteer is providing care that is not being compensated by the patient;
I HAVE READ AND UNDERSTAND THE ABOVE AND ACKOWLEDGE THAT I WILL BE TREATED BY AN EMPLOYEE AND/OR VOLUNTEER MEDICAL AND/OR DENTAL PROFESSIONAL, UNDERSTANDING THE LIMITATIONS ON THE RECOVERY OF DAMAGES DESCRIBED ABOVE FOR PATIENT.
AUTHORIZATION FOR TREATMENT
I HEREBY AUTHORIZE VOLUNTEERS IN MEDICINE STAFF AND VOLUNTEER PROFESSIONALS TO TREAT ME (IF PATIENT IS UNDER 18 YEARS OF AGE, PARENT MUST SIGN.)