FIREARMS SAFETY COUNSELING REPRESENTATION: PHYSICIAN QUALIFICATIONS AND LIABILITY
Part One: Qualifications
I affirm that I am certified to offer (Name of Patient: ), herineafter referred to as “the Patient”, qualified advice about firearms safety in the home, having received: 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.: _________________________________________________________________________ _________________________________________________________________________
Check one, as appropriate:
___
I represent that I have reviewed applicable scientific literature pertaining to defensive gun use and beneficial results of private firearms ownership. I further represent that I have reviewed all other relevant home safety issues with the Patient, including those relating to electricity, drains, disposals, compactors, garage 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, 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 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 reprerentative, 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:
Indicate if physician “REFUSED TO SIGN.” Have physician place a copy in your chart/medical record
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