Reginick Home Care Services – Non-Medical Transportation Consent Form
This consent form authorizes Reginick Home Care Services to provide non-medical and non-emergency transportation services for the individual listed below. Please review all sections carefully before signing.
Client Information
Client Name: ______________________________________
Date: ______________________________________
Phone Number: ______________________________________
Pickup Address: ______________________________________
Destination Address: ______________________________________
1. Consent for Transportation Services
I, the undersigned, authorize Reginick Home Care Services to provide non-medical transportation services for the client named above.
Transportation services may include assistance with transportation to medical appointments, errands, grocery shopping, social activities, pharmacy visits, and other approved destinations.
2. Acknowledgment of Non-Emergency Services
I understand and acknowledge that:
- Reginick Home Care Services provides non-medical transportation services only.
- This is NOT an emergency medical transportation service.
- Caregivers and transportation staff do not provide medical treatment or emergency medical care.
- In case of a medical emergency, 911 should be contacted immediately.
3. Client Condition Disclosure
I confirm that:
- The client is medically stable for non-emergency transportation.
- Any mobility limitations, medical conditions, behavioral concerns, or assistance needs have been fully disclosed.
- The client is able to safely participate in transportation services with the disclosed assistance needs.
4. Transportation Assistance Acknowledgment
I understand that transportation assistance may involve entering and exiting vehicles, walking assistance, wheelchair assistance, and other mobility-related support.
I acknowledge that transportation activities may involve certain risks including slips, falls, transfers, and movement-related incidents.
5. Liability Waiver
I acknowledge and agree that:
- Reginick Home Care Services is not responsible for complications related to pre-existing medical conditions.
- Transportation services involve inherent risks associated with movement and mobility assistance.
- Reginick Home Care Services shall not be held liable for injuries or incidents resulting from undisclosed medical or mobility conditions.
6. Personal Belongings
I understand that Reginick Home Care Services is not responsible for lost, stolen, or damaged personal belongings during transportation services.
7. Payment Responsibility
I agree to:
- Pay all applicable transportation service fees.
- Follow agreed pricing and scheduling terms.
- Provide timely cancellation notice when transportation services are no longer needed.
8. Authorization to Communicate
I authorize Reginick Home Care Services to communicate with family members, caregivers, healthcare offices, or authorized representatives when necessary to coordinate transportation services.
9. Consent Acknowledgment
By signing below, I confirm that I have read, understood, and voluntarily agree to the terms outlined in this consent form.
Signature
Client / Authorized Representative Name: ______________________________________
Signature: ______________________________________
Date: ______________________________________