TexasCHLforum.com

C-dub wrote:Any doc sign that form yet Jim?

Nope, but I have refused to go farther with one, and fired another.

I have fired a doctor because I felt she was anti-rights, and except for unplanned emergency room visits, this form goes with me to every doctor visit, just in case.

Physician
Qualifications and Liability

Firearms Safety Counseling Representation: Physician Qualifications and Liability
Part One: Qualifications
I, _______________________________ affirm that I am certified to offer my patient __________________________________ hereafter referred to as "the Patient," qualified advice about firearms safety in the home, having received the following training (specify course(s) of study):
___________________________________ ___________________________________
From (specify institution(s)):
___________________________________ ___________________________________
On (specify course completion date(s)):
___________________________________ ___________________________________ Resulting in (specify accreditation(s), certification(s), license(s) etc.):
___________________________________ ___________________________________

For Physician
Initial one, as appropriate:
______I represent that I have reviewed applicable scientific literature pertaining to defensive gun use, safety, storage, and beneficial results of private firearms ownership. I further represent that I have reviewed all other home safety issues with the Patient, including those relating to drains, disposals, compactors, doors, driveway safety, pool safety, pool fence codes and special locks for pool gates, auto safety, gas, broken glass, stored cleaning chemicals, buckets, toilets, sharp objects, garden tools, home tools, power tools, lawnmowers, lawn chemicals, scissors, needles, forks, knives, etc.
I also acknowledge that by receiving this document. I have been made aware that, in his inaugural address before the American Medical Association on June 20, 2001, new president Richard Corlin, MD, admitted "What we don't know about violence and guns is literally killing us . . . researchers do not have the data to tell how kids get guns, if trigger locks work, what the warning signs of violence in schools and at the workplace are, and other critical questions due to lack of research funding." (UPI).
In spite of this admission, I represent that I have sufficient data and expertise to provide expert and clinically sound advice to patients regarding firearms in the home.
or
___ I am knowingly engaging in Home/Firearms Safety Counseling without certification, license or formal training in Risk Management, and; I have not reviewed applicable scientific literature pertaining to defensive gun use, safety, storage, and beneficial results of private firearms ownership.

Part Two: Liability
I have determined, from a review of my medical malpractice insurance, that if I engage in an activity for which I am not certified, such as Firearms Safety Counseling, the carrier (check one as appropriate):

___will ___ will not

cover lawsuits resulting from neglect, lack of qualification, etc.
Insurance Carrier name, address and policy number insuring me for firearms safety expertise:

___________________________________

___________________________________

I further warrant that, should the Patient follow my firearm safety counseling and remove from the home and/or disable firearms with trigger locks or other mechanisms, and if the patient or a family member, friend or visitor is subsequently injured or killed as a result of said removal or disabling, that my malpractice insurance and/or personal assets will cover all actual and punitive damages resulting from a lawsuit initiated by the patient, the patient's legal representative or the patient's survivors.
Signature of attesting physician and date:

___________________________________

___________________________________

Name of attesting physician (please print):

___________________________________

___________________________________

Signature of patient and date:

___________________________________

___________________________________
Name of patient (please print):

___________________________________

Patient should indicate if physician REFUSED TO SIGN by initialing here:_____