Worthy Care Concierge Nursing, LLC Valley Road Wexford PA 15090 Phone (878) 229-2727
I, the above named patient, have read and understood this waiver and consent form. I understand that my nurse has the right to refuse treatment if the home environment is deemed unsafe. I agree to receive home care services as described. I understand the risks involved and give my informed consent for treatment.
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Welcome! Thank you for choosing Worthy Care Concierge Nursing, LLC for your home care needs. Please read this document carefully. It explains the nature of the services provided, your rights, and the risks involved. Your signature indicates that you understand and agree to these terms.
1. Description of Services As a registered nurse and owner of Worthy Care Concierge Nursing, LLC, I provide personalized home care services, including but not limited to health assessments, medication management, wound care, IV therapy, and health education. All services are provided in accordance with applicable laws and standards of practice.
2. Your Rights and Responsibilities - You have the right to receive safe, respectful, and confidential care. - You are responsible for providing accurate health information and informing me of any changes in your health status. - You have the right to ask questions and to refuse or discontinue any service at any time.
3. Safety and Environment The safety of both the client and the nurse is paramount. I reserve the right to assess the home environment before and during treatment. If I determine that the environment is unsafe or poses a risk to health or safety — such as hazards, unsafe conditions, or inability to provide proper care — I have the right to refuse or discontinue treatment at any time. In such cases, I will provide guidance on how to address safety concerns and may recommend alternative arrangements or referrals to other healthcare providers.
4. Risks and Limitations While I strive to provide the highest quality care, there are inherent risks with any medical treatment or intervention. These may include, but are not limited to, allergic reactions, infections, or complications related to procedures. I will take all appropriate precautions to minimize these risks.
5. Consent to Treatment By signing below, you acknowledge that you have been informed about the nature of the services and agree to receive care voluntarily. You understand that no guarantees can be made regarding specific outcomes.
6. Privacy and Confidentiality Your health information will be kept confidential in accordance with applicable laws. Information may be shared with other healthcare providers or family members only with your permission or as required by law.
7. Emergency Situations In case of an emergency, I will take appropriate action, including contacting emergency services. You agree to provide current contact information and communicate any emergency concerns promptly.
8. Liability Waiver and Professional Discretion I will perform my services with care and professionalism within the scope of my nursing practice. However, I am not responsible for any adverse outcomes resulting from your underlying health conditions, non-compliance with medical advice, unsafe home environment, or unforeseen complications. I reserve the right to refuse treatment if I believe it is unsafe to proceed.
Acknowledgment and Consent
By signing below, I acknowledge that I have read and understand this waiver and consent form, and that I understand the risks involved and give my informed consent for treatment.
