Medical Liability Release
Prepared by: [YOUR NAME]
Company Name: [YOUR COMPANY NAME]
Company Number: [YOUR COMPANY NUMBER]
Company Address: [YOUR COMPANY ADDRESS]
Company Website: [YOUR COMPANY WEBSITE]
Company Social Media: [YOUR COMPANY SOCIAL MEDIA]
Date: August 22, 2050
Introduction:
This Medical Liability Release is designed to acknowledge and accept the inherent risks associated with emergency medical care provided by [YOUR COMPANY NAME]. By signing this document, you agree to release [YOUR COMPANY NAME], its employees, and affiliated healthcare providers from liability for any claims or damages that may arise from the emergency medical care you receive. Please review the following terms carefully before signing.
Medical Liability Release
I, Brian Thompson, acknowledge that I am seeking emergency medical care from [YOUR COMPANY NAME]. I understand and accept that emergency medical care may involve certain risks and uncertainties. I agree to the following terms:
Acknowledgment of Risk: I understand that emergency medical care can involve risks, including but not limited to complications, adverse reactions, or unexpected outcomes. I acknowledge that these risks have been explained to me and that I have had the opportunity to ask questions.
Release of Liability: I hereby release and hold harmless [YOUR COMPANY NAME], its employees, agents, and affiliated healthcare providers from any and all claims, demands, or causes of action arising out of or related to the emergency medical care provided, except in cases of gross negligence or willful misconduct.
Consent to Treatment: I consent to receive emergency medical care and authorize [YOUR COMPANY NAME] to perform any necessary procedures or treatments as deemed appropriate by the medical personnel.
Understanding and Agreement: I have read and fully understand this Medical Liability Release. By signing below, I voluntarily agree to its terms and conditions.
Patient Information Table
Patient Name | Date of Birth | Patient Address | Emergency Contact | Emergency Contact Phone |
|---|
Brian Thompson | April 12, 1975 | 789 Maple Avenue, Apt 12B, Health City, HC 54321 | Alice Thompson | (555) 987-6543 |
Signature Section
By signing this release, I confirm that I have read and understood the terms and conditions outlined above.
Signature of Patient
Date: August 22, 2050
Signature of Witness
Date: August 22, 2050
For any questions or further information, please contact [YOUR COMPANY NAME] at [YOUR EMAIL] or visit our website at [YOUR COMPANY WEBSITE].
Release of Liability Templates @ Template.net
