This Authorisation is given by the Resident in favour of Roots to Recovery (hereinafter referred to as "the Facility") for the duration of his stay at the Facility, and remains in force unless and until expressly revoked in writing.
RESIDENT PARTICULARS
CLINICAL SUMMARY
CURRENT MEDICATION
| Medication | Dose | Frequency | Reason for Use | Prescriber |
|---|---|---|---|---|
Authorisation for Emergency Medical Action
I, the Resident, expressly authorise the Facility, acting through any authorised staff member, to take any of the following actions where, in the reasonable opinion of the Facility, my health or safety so requires:
- to call an ambulance service and arrange transport to the nearest appropriate hospital or emergency department;
- to contact the emergency doctor appointed by the Facility;
- to contact the certified homeopath retained by the Facility, where homeopathic care is appropriate;
- to contact my general practitioner, specialist or psychiatrist on my behalf;
- to contact my Responsible Person and family members;
- to release my medical information, medication record, substance use history and any other relevant information to treating practitioners, paramedics, hospital staff and admitting clinicians;
- to consent on my behalf to the administration of first aid, emergency intervention, pain relief, stabilising treatment, intravenous fluids and any other treatment reasonably required in the emergency;
- to consent on my behalf to admission to a hospital, observation ward or psychiatric facility, where this is reasonably required;
- to consent on my behalf to diagnostic procedures, including blood tests, imaging and any other investigation reasonably required;
- to make any practical decision regarding my care that cannot reasonably wait until I am able to make the decision myself or until the Responsible Person can be contacted.
Cautious Approach
I acknowledge and accept that the Facility will generally err on the side of caution. Where there is any reasonable doubt as to the seriousness of my condition, the Facility may activate this Authorisation.
I confirm that I will not hold the Facility, its owners, directors, managers, employees, contractors or agents liable for any decision made in good faith under this Authorisation.
Notification of the Responsible Person
I confirm that the Facility will notify my Responsible Person of any emergency medical event as soon as reasonably possible, and normally within two (2) hours of the event.
Where the Responsible Person cannot be reached, the Facility may contact the next of kin or alternative emergency contact recorded in my admission file.
Financial Responsibility
I accept liability for all costs arising from emergency medical action taken under this Authorisation, including ambulance call-outs, emergency consultations, hospital admission fees, diagnostic procedures, medication and after-care.
I authorise the Facility to apply my emergency medical deposit of R2 000,00 towards such costs.
Where the deposit is insufficient, I undertake to settle the balance on presentation of an invoice. My Responsible Person accepts joint and several liability where the Responsible Person has signed the Responsible Party Agreement.
Disclosure of Information
I authorise the Facility to disclose to treating practitioners, paramedics and hospital staff any information that is relevant to the assessment and treatment of my condition, including:
- my full medical history;
- my mental health history;
- my substance use history, including current and recent use;
- my current medication;
- my drug testing record at the Facility;
- any prior overdose, withdrawal complication or psychiatric episode known to the Facility;
- any other matter reasonably required for safe and effective treatment.
Refusal of Specific Treatment
I record below any specific treatment, medication or intervention that I refuse to receive in any circumstance. Subject to such refusal, I authorise the Facility to act as set out above.
Living Will / Advance Directive
I record below whether I hold any living will or advance directive that should be considered in the event of an emergency. Where applicable, I undertake to provide the Facility with a copy.
Duration of this Authorisation
This Authorisation takes effect on the date of signature and remains in force for the duration of my stay at the Facility, including any period of absence on leave, and including the period until I am formally signed out.
I may revoke this Authorisation at any time by written notice delivered to the Facility Manager. Revocation does not affect any action taken under this Authorisation before receipt of the notice of revocation.
RESIDENT DECLARATION
I, the undersigned Resident, declare that:
- I have read this Authorisation in full and understand its contents.
- I sign this Authorisation freely, voluntarily and of sound mind.
- The information I have provided in this Authorisation is true, complete and accurate.
- I authorise the Facility to act on this Authorisation in any emergency that arises during my stay.
RESPONSIBLE PERSON ACKNOWLEDGEMENT
I, the Responsible Person, have read this Authorisation and acknowledge the actions that the Facility is authorised to take in the event of a medical emergency. I confirm that I will be available to receive emergency communication and to attend to the Resident when reasonably required.
FACILITY CONFIRMATION