Consent and Waiver of Liability
I certify that the information given on the Patient Health Questionnaire is accurate. I understand the importance of a truthful health history and that my doctor and his/her staff will rely on this information for treating me. I understand all records, x-rays, models, etc., will remain the property of Hope Medivan. I grant permission to the Physician/Dentist to administer anesthetics, or remove any tissue and/or structure, and to employ such operative and technical procedures as are necessary or advisable for purpose of treatment and diagnosis of the above named patient. Hope Medivan may take photographs necessary for teaching purposes. Also, Physician/Dentist may release records only to a physician or dentist to verify a diagnosis.
Notice to Patients
This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) functions by any free clinic volunteer health care practitioner who the Department of Health and Human Services has deemed provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related to be an employee of the Public Health Service.
The above Federal law and other State and Federal laws including the Federal Volunteer Protection Act of 1997 may cover certain free clinic health care professionals providing health care services to patients at this free clinic.
Waiver of Liability
I have received and reviewed the Patient Pamphlet of the HOPE Medivan and I, for myself and anyone entitled to act on my behalf, hereby release and hold harmless the HOPE Medivan and its agents, employees, representatives, officers, and directors, from any and all liability, cost damages, causes of action suits, and/or claims of any kind or nature (collectively the ‘Claims’) related to or arising out of my receiving volunteer services from the HOPE Medivan, even in the event such liability may arise out of negligence or carelessness on the part of the provider named in this waiver, to the fullest extent permitted by law.
This release applies to all Claims, whether known or unknown, foreseen or unforeseen, that I have at any time against HOPE Medivan and its agents, employees, representatives, officers and directors.
This waiver shall be governed and interpreted according to the laws of the State of California. Any dispute relating to this waiver will be settled by binding arbitration in a venue and jurisdiction being in Stanislaus County, California. As indicated by my signature below, I have read and fully understand the terms of this waiver. If I am under 18 years of age, I have reviewed this release of liability with at least one of my parents or guardians, and my parents or guardians have indicated acceptance of the terms of the release by signing below.
I, my minor child, or a minor child under my legal guardianship (individually and collectively referred to as “Participants”), intend to attend or participate in one or more programs of The House Modesto or its related entities or integrated auxiliaries (collectively, ‘THM’).
In consideration of this participation, Participants grant to THM all right, title, and interest in any and all photographs, images, video, and audio recordings of Participants or Participants’ likeness or voice made by THM in connection with such participation (the “Media”).
Participants authorize THM to publish the Media in THM publication, promotional, and educational materials, on its website and social media accounts; in any television, radio, or internet broadcast; and in any other format for non-commercial use. Participants understand and agree that they will not receive compensation for any use of the Media in such manner.
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Below is the Signature.