Nursing Home Disclaimer Form
This form serves to acknowledge the understanding and acceptance of the conditions under which care is provided by [Your Company Name]. It is imperative that family members or legal guardians read and comprehend the entirety of this document to ensure a mutual understanding of the responsibilities and limitations of [Your Company Name].
Resident Information | Full Name | |
| Date of Birth | [MM-DD-YYYY] |
Family Member/Legal Guardian | Full Name | |
| Relationship to Resident | |
| Contact Number | |
Acknowledgment of Risks | Initials to Acknowledge Understanding | |
Assumption of Responsibility | Initials to Acknowledge Assumption of Responsibility | |
Liability Release | Initials to Release [Your Company Name] from Liability | |
Signature
Signature of Family Member/Legal Guardian
Date: [MM-DD-YYYY]
Please read the following Nursing Home Disclaimer:
I, [Your Name], understand the risks and consequences involved in letting my loved one reside in a nursing home. I assume full responsibility for my decision and hold [Your Company Name] free of any liability.
I, [Your Name], have read and understood the Nursing Home Disclaimer.
This Nursing Home Disclaimer Form is a crucial document that clarifies the scope of care and responsibilities of [Your Nursing Home Name] and the resident's family members or legal guardians. Signing this form indicates a comprehensive understanding and agreement to the terms laid out, ensuring a transparent and cooperative relationship between all parties involved.
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