Consent for Testing

          In order to comply with the Occupational Safety and Health Administration Bloodbourne Pathogen Regulation (OSHA), we are requesting your consent to submit to testing of your blood for bloodbourne pathogens (Hepatitis B, Hepatitis C or HIV) if and exposure occurs (needlestick injury, blood spatter) to one of our staff.  Testing will be done at no cost to you.  All information regarding an exposure is confidential.

Signature_______________________________________     Date____________________

Privacy Statement

          In order to comply with new privacy rules governing the sharing of medical information for billing purposes, we need your permission.  Please sign this form to allow for the billing of insurance for your care.  Please check the appropriate spaces for additional permissions.

____ May leave messages on my voice mail / answering machine.
____ May fax information to my fax number.
____ May share information with the following members of my family.
          ______________________________________
          ______________________________________
          ______________________________________
          ______________________________________

Signature_______________________________________     Date____________________