Patient Consent Form

Helderberg Hospice – 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’s care 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 injuries sustained 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.

Other Forms To Complete: PATIENT MEDICAL REFERRAL | PATIENT PERSONAL INFORMATION