• THIS REGISTRATION PROCESS TAKES ABOUT 3 MINUTES PER PERSON
• READ EACH SECTION CAREFULLY BEFORE ANSWERING
• YOU WILL ENTER YOUR BAND NUMBER IN THIS REGISTRATION
• YOU CANNOT ENTER A BAND NUMBER TWICE, ONLY ONCE IN A REGISTRATION
• YOU CANNOT LEAVE THE LINE, IF YOU LEAVE THE LINE YOU LOSE YOUR PLACE
• ANSWER THE QUESTIONS TRUTHFULLY AND ACCURATLLY SO YOU DON'T LOSE YOUR PLACE IN LINE

Patient Application and Consent for Health Care

PATIENT CONSENT FOR GENERAL PRIMARY CARE

I hereby authorize the Physicians, Nurses, Dentists and/or other health care providers of Adventist Medical Evangelism Network (AMEN), some of whom might be closely supervised advanced students, to examine and/or treat me and/or my dependent as named above. I understand that it is my responsibility to notify AMEN (530-883-8061) of any changes in contact information, such as change of address or new telephone number when follow-up may be necessary.

NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING

As a health care provider, we are making available to you the following notice:

2. If one of our health care professionals, workers or employees should be directly exposed to your blood or body fluids in a way that may transmit disease, your blood will be tested for infection with human immunodeficiency virus (the “AIDS” virus), as well as for Hepatitis B and C. A physician or other health care provider will tell you the result of the test. By  checking “Yes” below, you are deemed to have consented to the release of the test results to the person exposed.
3. If you should be directly exposed to blood or body fluids of one of our health care professional, workers or employees in a way that may transmit the disease, that person’s blood will be tested for infection with human immunodeficiency    virus (the “AIDS” virus), as well as for Hepatitis B and A physician or other health care provider will tell you and that person the results of the test.

 IMPORTANT NOTICE

AMEN is a 501(c)3 charity with no paid volunteers and is NOT part of a government program. AMEN volunteers may not be able to provide you with all the services you need, but if you would like to consult with our volunteer team and receive the type of treatment being offered today, PLEASE READ THE PATIENT WAIVER BELOW VERY CAREFULLY.

PATIENT WAIVER

Dental Patients Note: While the volunteer hygienists, dentists and oral surgeons offer high quality procedures with good equipment, I understand that because of the number of people needing to be seen, I might not receive multiple extrac-     tions or multiple fillings. I understand that I might have certain medical conditions which would keep me from having the  type of treatment I am requesting. I also understand that the dental care providers are volunteers, some from out-of-town,  and are not available for follow-up care in the event of complications. I agree to seek any follow-up care I might need

from my local dentist, health department, family physician or a hospital emergency room.

Vision Patients Note: Prescription glasses have a 30 days warranty from defect. If the glasses are damaged upon arrival, you must notify AMEN within 30 days to receive a replacement at no cost to you. However, AMEN is not responsible for loss or damages incurred by the patient, whether accidentally or purposely.

In consideration of the free health care services received on the date below, I, for myself and anyone entitled to claim through me, do hereby waive and release AMEN, and any persons or organizations acting on their behalf or sponsoring    or volunteering at this clinic, from all claims of liability arising out of my acceptance of such free care including, but not limited to medical, surgical, dental, vision and/or other health care or medical advice.

I grant to AMEN and their agents the right to use my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing AMEN and their activities in all form of media in perpetuity.

I the undersigned patient consent to the release of my patient records to other licensed health care professionals as nec- essary. I have read, or had read to me, and understand and agree to all of the above.