Patient Consent for Bloodborne Pathogen Testing Form

In order to comply with the Occupational Safety & Health Administration (OSHA) Bloodborne Pathogen Regulation, we are requesting your consent to submit to testing for bloodborne pathogens if an exposure occurs (needlestick injury, blood splatter) to one of the staff members. Testing will be done at no cost to you. You are deemed to have consented to the release of the test results to the person exposed. All information regarding an exposure is confidential.

If you should be directly exposed to bloodborne pathogens of a health care professional, worker or employee in a way that transmit disease; that person will submit to testing for bloodborne pathogens. A physician or other health care provider will tell you and that person the result of the test.

I understand that this consent will remain in effect as long as my dependent or I receive care from Dr. Hedy Atashbar, D.D.S., LLC or until I withdraw it.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Guardian Signature:

Date:

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US

acknowledge that I received and/or reviewed the office Privacy Policy Notice for Dr. Hedy Atashbar.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Guardian Signature:

Date:

******In case you do not agree to sign this form, our office must indicate why you declined to do so*****

Reason for patient’s refusal:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Privacy Director’s signature:

Date:

Your information will be encrypted.